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Lingnan Modern Clinics in Surgery ›› 2020, Vol. 20 ›› Issue (02): 219-224.DOI: 10.3969/j.issn.1009-976X.2020.02.018

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Safety and efficacy of intravenous tirofiban and loading dose of clopidogrel in stent-assisted embolization of acute ruptured aneurysms

  

  1. Department of Vascular and Interventional Neurosurgery, The First People??s Hospital of Foshan, Foshan, Guangdong province, 528000, China
  • Contact: LIAO Xu-xing

静脉应用替罗非班与术前顿服负荷剂量氯吡格雷在急性期破裂动脉瘤支架辅助栓塞中的安全性和有效性

  

  1. 佛山市第一人民医院血管及介入神经外科,广东佛山 528000
  • 通讯作者: 廖旭兴

Abstract: [Abstract] Objective To evaluate the safety and efficacy of intravenous tirofiban and loading dose of clopidogrel in stent-assisted coil embolization of acute ruptured aneurysms. Methods A retrospective analysis was made of the patients with ruptured intracranial aneurysms treated continuously from January 2012 to October 2018. All patients were treated with stent-assisted coil embolization in acute stage. Tirofiban was injected intravenously 15 minutes before stent release in tirofiban group, and clopidogrel was given a load dose of clopidogrel (300 mg) 2 hours before stent release in clopidogrel group. The hemorrhage and thromboembolism events of two kinds of antiplatelet aggregation drugs were observed and analyzed. Results Thirty-eight ruptured aneurysms of 36 patients in tirofiban group were treated. Two patients (5.6%) had new thrombosis during operation, three patients (8.3%) had acute cerebral infarction after operation, two patients?? (5.6%) aneurysms had ruptured during operation, and two patients had late hemorrhage after ventricular drilling and drainage. There was no significant difference in platelet count (P=0.136). Thirty cases with GOS score (≥4). In clopidogrel group, 41 ruptured aneurysms were treated in 37 patients, 2 patients (4.9%) had acute cerebral infarction after operation, 2 patients?? (4.9%)aneurysms had ruptured during operation, 3 patients?? (7.3%)aneurysms had ruptured after operation, and 1 patient had puncture bleeding after ventricular drilling and drainage. Platelet count decreased significantly (P=0.000). 26 cases with GOS score (≥4). Conclusion Intravenous application of tirofiban during stent-assisted coil embolization of ruptured aneurysms in acute phase showed lower ischemia and hemorrhage events. In particular, tirofiban can dissolve newly generated thrombus during operation, and can be used as an alternative drug for anti-platelet aggregation in perioperative period.

Key words: stent, tirofiban, thrombosis , ruptured aneurysm, hemorrhage

摘要: 静脉应用替罗非班与术前顿服负荷剂量氯吡格雷在急性期破裂动脉瘤支架辅助栓塞中的安全性和有效性

静脉应用替罗非班与术前顿服负荷剂量氯吡格雷在急性期破裂动脉瘤支架辅助栓塞中的安全性和有效性

董安石, 廖旭兴*, 钟伟健, 刘鑫鑫, 周思捷, 梁铭钦, 林海波, 罗杰,邓其峻

[摘要] 目的 评估静脉应用替罗非班与鼻饲负荷剂量氯吡格雷在急性期破裂动脉瘤支架辅助弹簧圈栓塞的安全性和有效性。方法 回顾性分析2012年1月至2018年10月连续性治疗的颅内动脉瘤破裂出血病人,均急性期应用支架辅助弹簧圈栓塞动脉瘤。替罗非班组支架释放前15分钟应用替罗非班,氯吡格雷组术前2小时顿服负荷剂量氯吡格雷(300 mg)。观察分析2种抗血小板聚集药物出血和血栓栓塞事件。结果 替罗非班组36例病人的38个破裂动脉瘤接受治疗。术中血栓形成2例(5.6%);术后急性脑梗塞3例(8.3%);术中动脉瘤破裂2例(5.6%);脑室钻孔引流穿刺道后期出血2例。血小板计数降低无统计学意义(P=0.136)。GOS评分≥4分30例。氯吡格雷组37例病人41个破裂动脉瘤接受治疗,术后急性脑梗塞2例(4.9%);术中动脉瘤破裂2例(4.9%),术后破裂3例(7.3%);脑室钻孔引流后期穿刺道出血1例。血小板计数明显降低(P=0.000)。GOS评分≥4分26例。结论 静脉应用替罗非班在急性期破裂动脉瘤支架辅助弹簧圈栓塞过程中显示出较低的缺血及出血事件,可溶解术中新产生的血栓,可作为围手术期抗血小板聚集的替代药物。

[关键词] 替罗非班;破裂动脉瘤;支架;出血;血栓

在急性期破裂动脉瘤介入治疗过程中,临时应用支架辅助栓塞动脉瘤有时难以避免。急诊应用支架会增加血栓风险,需行抗血小板治疗[1,2]。替罗非班作为新型抗血小板聚集药物,既可预防应用抑制血小板聚集,又可在血栓形成后应急使用[3-6]。我们回顾性分析2012年1月至2018年10月73例急性期破裂动脉瘤患者,术前分别静脉应用替罗非班和负荷剂量氯吡格雷(300mg)抗血小板聚集。现介绍如下。

1 资料与方法

1.1 一般资料

回顾性分析2012年1月至2018年10月连续性治疗的一系列急性期73例病人。替罗非班组36人,男12例,女24例,年龄29~80岁,平均57.5±11.7岁。破裂动脉瘤38个,前循环27个,后循环9个。氯吡格雷组共37人,男10例,女27例,年龄31~78岁,平均56.7±11.8岁。破裂动脉瘤41个,前循环36个,后循环5个(表1)。

表1 急性期破裂动脉瘤部位及比例[n(%)]

动脉瘤部位颈内动脉床突段眼动脉后交通动脉脉络膜前动脉前交通动脉大脑中动脉椎动脉小脑后下动脉基底动脉大脑后动脉P2总计数量及比例替罗非班组(n=36)0 1(2.6)16(42.0)0 9(23.7)3(8.0)5(13.2)0 4(10.5)0 38(100)氯吡格雷组(n=37)2(4.9)2(4.9)23(56.1)2(4.9)5(12.2)2(4.9)1(2.4)2(4.9)1(2.4)1(2.4)41(100)

1.1.1 纳入排除标准 纳入标准:①发现蛛网膜下腔出血至介入手术时间≤3天;②术前影像学证实动脉瘤破裂者;③术中使用支架者。排除标准:①发病前口服阿司匹林或氯吡格雷者;②术严重肾功能不全者(肌酐清除率<30 mL/min)。

1.1.2 急性血栓栓塞事件和颅内出血的定义 急性血栓栓塞事件定义为术中血管造影可见脑血管完全或部分闭塞,或术后24小时内影像学可见新发梗塞灶。颅内出血的定义为:造影剂在血管造影上的外溢或术后头部计算机断层扫描上的新发出血(脑组织、蛛网膜下腔、脑室内)。

1.2 方法

1.2.1 药物使用方法 替罗非班组术中支架释放或半释放后使用替罗非班[首先3分钟内静脉团注5 μg/kg的替罗非班负荷量,然后以2.5 μg/kg·h的速率经静脉微泵注入]并持续24小时。从静推替罗非班开始计时,18小时后开始使用氯吡格雷(波立维)300 mg顿服,与替罗非班重叠6小时。氯吡格雷(波立维)300 mg顿服24小时后开始使用常规剂量双抗(每日口服阿司匹林100 mg,氯吡格雷75 mg),阿司匹林持续口服半年,氯吡格雷持续3个月。

氯吡格雷组术前2小时口服或鼻饲300 mg氯吡格雷(波立维),24小时后开始使用常规剂量双抗,阿司匹林持续口服半年,氯吡格雷持续3个月。

1.2.2 介入治疗方法 全麻后采用改良Seldinger技术穿刺股动脉,术中全身肝素化(初始833 IU/kg,后每1小时追加417I U/kg)DSA选择合适的工作角度,导引导管在透视下置于术前预定部位。先将支架导管置于动脉瘤远端,微导管在导丝指引下超选至动脉瘤瘤腔填塞弹簧圈,支架后释放或半释放,填塞满意后即刻行工作位、正侧位及3D造影评估动脉瘤栓塞效果及栓塞前后载瘤动脉及周围动脉情况。

1.3 疗效评价

术中记录是否存在出血或缺血事件;术后24小时内更换抗血小板药物前复查头CT了解是否存在新发梗塞或出血。抽血常规与术前对比了解血小板及血红蛋白变化。采用格拉斯哥预后评分(glasgow outcome score,GOS)评价患者临床预后,GOS≥4分为预后良好。

1.4 统计学分析

采用SPSS 19.0统计学分析软件。卡方检验或Fisher检验比较两组出血及缺血事件;计量资料以均数±标准差表示;采用配对t检验比较两组应用替罗非班前后血红蛋白及血小板计数的变化。P值均为双侧,P<0.05为有统计学意义。

2 结果

2.1 一般数据

替罗非班组36例病人的38个破裂动脉瘤接受了栓塞治疗,使用弹簧圈189个,Solitaire支架3枚,Enterprise支架37枚。GOS预后评分1分0例,2分1例,3分5例,4分1例,5分29例。GOS≥4分30例(GOS 2分为术中动脉瘤破裂双瞳孔散大者;5例GOS为3分患者其中1例术后急性脑干小脑梗塞,3例术前均昏迷,GCS 5~8分,1例为高龄患者血管痉挛反应较重)。氯吡格雷组37例病人的41个破裂动脉瘤接受了栓塞治疗,共用弹簧圈206个,Enterprise支架 36枚,Solitaire 4枚。GOS预后评分1分2例,2分1例,3分8例,4分1例,5分25例。GOS≥4分者共26例。

替罗非班组入院血小板(88~408)×109/L。平均(257.03±64.49)×109/L。应用替罗非班18小时的血小板(112~389)×109/L,平均(247.86±58.28)×109/L。入院血红蛋白107~190 g/L,平均134.00±16.21 g/L。应用替罗非班18小时血红蛋白98~174 g/L,平均123.75±17.32 g/L。应用替罗非班前后血红蛋白下降具有统计学意义(P<0.001),血小板前后下降的差异无统计学意义(P=0.136)。

氯吡格雷组组入院血小板(112~404)×109/L。平均(231.24±77.56)×109/L,应用氯吡格雷18小时血小板(90~396)×109/L,平均(206.05±69.30)×109/L。入院血红蛋白95~160 g/L,平均 127.30±18.66 g/L。氯吡格雷组血小板数目下降及血红蛋白数值下降均有统计学意义(P<0.001)。(表2)

两组血小板下降值(氯吡格雷组入院血小板数值减去术后血小板数值与替洛罗非班组入院血小板数值减去术后血小板数)比较P=0.63,无统计学意义。表明氯吡格雷组与替罗非班组均可存在血小板下降,但差别无统计学意义。两组血红蛋白下降值比较,P=0.392,无统计学意义。表明氯吡格雷组与替罗非班组均有血红蛋白下降,但两组差别无统计学意义。

表2 手术前后2组血小板计数及血红蛋白比较

时间术前术后t值P值替罗非班组血小板计数256.03±64.00 246.26±58.34 1.55 0.136血红蛋白计数133.85±16.68 123.71±17.83 6.17 0.000氯吡格雷组血小板计数231.2±77.56 206.0±69.30 4.19 0.000血红蛋白计数127.3±18.66 115.1±15.81 7.89 0.000

2.2 效果

GOS≥4分表示为预后良好。替罗非班组GOS≥4分为83.8%较氯吡格雷组(70.3%)仍具有较好的预后率,但差异无统计学意义(P=0.187)。与氯吡格雷相比,替罗非班并未增加急性期支架辅助动脉瘤栓塞治疗过程中动脉瘤破裂、术中血栓形成及脑梗死风险,没有增加侧脑室钻孔外引流穿刺道出血风险。且整体良好预后率(83.3%)较氯吡格雷组(70.3%)较好。

2.3 并发症及处理

替罗非班组急性期支架内血栓形成2例(5.6%),其中1例为右侧椎动脉夹层动脉瘤支架内血栓,考虑为支架进入假腔打开后撕裂内膜,应用替罗非班局部微导管持续推注6 mL后血栓溶解(GOS 5分);另一例为后交通动脉瘤术中弹簧圈脱出,术中应急使用支架,指引导管铲掉了内膜斑块,血栓卡在支架末端,应用替罗非班10 mL(500 μg)局部推注无好转,后颈内动脉闭塞,但对侧经前交通代偿良好,患者预后良好(GOS 5分)。氯吡格雷组无急诊术中血栓形成。虽然替罗非班组存在2例术中支架内血栓,但无统计学意义(图1)。

图1 A右侧椎动脉动脉瘤,位于PICA以远;B术中支架半释放填塞弹簧圈;C术中急性血栓形成;D、E手推造影基底动脉上部可见造影剂显影;F、G替罗非班微导管内溶栓;H血流恢复通畅及近端再贴附1枚支架

2.3.1 替罗非班组 ①替罗非班组急性新发脑梗塞3例(8.3%),为1例左侧椎动脉和2例基底动脉动脉瘤:左侧椎动脉为小脑后下动脉起始处夹层动脉瘤,应用2枚Enterprise支架辅助栓塞,术后出现右侧桥臂及小脑梗塞。仔细分析造影发现右侧小脑前下动脉起始处细小,术后仍可辨认。右侧小脑后下动脉供应部分小脑前下动脉供血区。后期出现颅内感染及脑积水,先后3次腰大池外引流。患者出院时左侧肢体肌力2级,右下肢肌力1级(GOS 3分)。2例基底动脉动脉瘤分别为基底动脉顶端囊性及基底动脉夹层动脉瘤,基底动脉顶端动脉瘤为术中破裂患者,术中出现双瞳孔散大,术后头CT右侧丘脑、桥脑、左侧小脑梗塞。均保守治疗,但后期缺血缺氧性脑病表现,患者长期昏迷(GOS 2分)。另一例为基底动脉夹层动脉瘤,术后头CT即有右侧桥脑,左侧小脑梗塞。出现右眼外展障碍,伸舌左偏。术后仔细分析发现支架尾端着陆点插入小脑前下动脉起始处,考虑为支架打开后再次撕裂夹层至AICA起始或支架影响脑干穿支动脉,后2次造影复查血管夹层仍存在且有扩张(GOS 4分)。3例急性脑梗塞患者除1例椎动脉夹层原因不清外,另外2例基底动脉1例术中破裂,1例支架近端着陆点进入AICA起始,与替罗非班无明显关系。

②替罗非班组动脉瘤破裂2例(5.6%),均为术中破裂。1例基底动脉顶端宽颈动脉瘤拟行双导管栓塞,完成成篮圈后应用另一条微导管继续栓塞时弹簧圈突入左侧大脑后动脉导致该血管显影不清,随即撤除动脉瘤内弹簧圈,左侧大脑后动脉处置入支架,再次填塞成篮圈时出现明显血压升高,心率加快,双瞳孔散大,此时已应用替罗非班,加快填塞弹簧圈后止血,急诊钻孔及气管切开。但术后出现弥漫性脑肿胀及脑积水,出院GOS 2分。另外1例前交通动脉瘤术中可见弹簧圈1个环突出动脉瘤,此时已打开支架及应用替罗非班,但未出现明显血压及心率改变,继续加快填塞后止血(GOS 5分)。2例术后头CT均见蛛网膜下腔出血及侧脑室后角血肿,未见脑内血肿。③替罗非班组栓塞前脑室钻孔外引流1例(2.8%),栓塞后立即钻孔3例(8.3%),术后复查头CT未见穿刺道及脑室内出血,但后期服用双抗后穿刺道出血2例(5.6%),分别为术前钻孔1例(术后4天穿刺道出血)及术后钻孔1例(术后7天穿刺道出血)。出血量均较少,约2周后均自行吸收。氯吡格雷组脑室钻孔外引流2例,均为术后24小时内,1例穿刺道未见渗血,1例可见出血(术后3天穿刺道出血)。继续口服双抗未见出血增加,约2周后穿刺道血肿消失。穿刺道出血继续应用双抗无一例外未见出血增多。

2.3.2 氯吡格雷组 ①急性脑梗塞2例(5.4%),其中1例为右侧后交通动脉瘤,术中支架释放时略有移位,支架远端1个铆钉点进入脉络膜前动脉开口处,术后出现对侧肢体乏力,复查头CT可见该供血区域梗塞,但患者经康复后预后尚可(GOS 5分)。另一例患者因术前突发呼吸骤停行心肺复苏及电除颤,术后可见大面积缺血缺氧。虽然替罗非班组脑梗塞发病率高,但无统计学意义(P=1.00)。急性脑梗塞替罗非班组3/36=8.3%,氯吡格雷组2/37=5.4%,无统计学意义(P>0.05)。②氯吡格雷组术中动脉瘤破裂3例(8.1%),其中1例前交通动脉瘤为造影时突发心率快,血压高,急诊沟通后栓塞,预后GOS 4分。另外2例后交通动脉瘤1例为弹簧圈1个环突出动脉瘤外,紧急中和肝素后继续填塞(GOS 5分),另一例为术中弹簧圈解旋,牵拉时支架移位,弹簧圈1个环突出瘤体,继续填塞后止血GOS(5分)。另有3例术后破裂,1例后交通动脉瘤为术后3小时突发血压升高,呼吸停止,考虑与术中动脉瘤填塞欠致密有关。1例后交通动脉瘤术后麻醉复苏时患者持续昏迷,复查头CT见左颞叶血肿增多,再行开颅手术可见动脉瘤子囊仍渗血,考虑动脉瘤子囊未行致密栓塞(GOS 3分)。1例后交通夹层动脉瘤患者术前出现自主呼吸停止,抢救后可脱机自主呼吸,GCS 5分,术后24天突发再次破裂导致呼吸心跳骤停(GOS 1分),考虑为夹层动脉瘤再次破裂。虽然氯吡格雷组术中破裂率略高,但无统计学意义。③氯吡格雷组脑室钻孔外引流2例,均为术后24小时内,1例穿刺道未见渗血,1例可见出血(术后3天穿刺道出血)。继续口服双抗未见出血增加,约2周后穿刺道血肿消失。穿刺道出血继续应用双抗无一例外未见出血增多。

3 讨论

急性期使用支架辅助弹簧圈栓塞动脉瘤需使用抗血小板聚集药物,但阿司匹林和氯吡格雷均存在起效慢,半衰期长等问题[2]。替罗非班作为一种可逆性非肽类血小板糖蛋白Ⅱb/Ⅲa受体拮抗剂。静脉给药后5分钟起效,30分钟后抑制率高于90%,半衰期约1.4~1.8小时。其抑制血小板聚集作用具有可逆性,停止注射4小时后血小板聚集和出血时间逐渐回到基线。负载剂量300 mg氯吡格雷2~4小时达到血小板抑制反应水平,停用5天消退。支架辅助弹簧圈栓塞动脉瘤容易引起脑梗塞。术后急性新发梗塞主要集中在围手术期动脉瘤破裂、后循环夹层动脉瘤及支架移位进入分支血管起始[2]。本组急性期脑梗塞替罗非班组3例(8.3%),氯吡格雷组2例(5.4%)。替罗非班组梗塞均为椎基底动脉动脉瘤。Nakajima S等[7]认为椎基底动脉动脉瘤合并蛛网膜下腔出血栓塞术后脑梗死比例明显增高。

动脉瘤栓塞过程中,血栓发生率达3%~10%,尤其应用支架后[5,8],部分可致永久性功能缺陷[10];替罗非班可溶解动脉瘤栓塞过程中载瘤动脉新形成的血栓[5,10-16],在蛛网膜下腔出血患者应用替罗非班同样是安全的[11,17]。在我们的研究中,应用替罗非班溶解了1例夹层动脉瘤支架进入假腔后急性血栓形成,术后未见出血及脑梗死。同样支持以上观点。其溶解新发血栓机制可能为①抑制血小板聚集导致血小板体积减小并抑制凝血酶形成②阻止血小板来源的局部溶栓抑制因子释放。③降解已聚集的血小板启动内源性纤溶系统[5]。Chalouhi[6]认为支架辅助栓塞动脉瘤术中应用替罗非班整体破裂率高达18.8%。本研究中替罗非班组术中破裂率2/36(5.6%)略低于氯吡格雷组3/37(8.1%),但无统计学意义(P=0.261)。kim[3]报道了破裂动脉瘤支架辅助动脉瘤栓塞术中应用替罗非班40例患者41例动脉瘤仅有2例术中破裂(4.9%),与本组结果相当。动脉瘤破裂出血主要集中在栓塞过程中,也有在造影时和术后。栓塞过程中需注意要避免反复调整导管及弹簧圈,一旦发现动脉瘤破裂应立即中和肝素,控制血压、加快填塞及减少造影剂推注。

文献显示常规钻孔外引流出血的风险5%~6%[18,19],然而蛛网膜下腔出血患者侧脑室钻孔外引流相关的出血率为 15%~20%[20,21]。Markus Bruder[23]等报道的一组数据中氯吡格雷组25例钻孔外引流中9例出现穿刺道出血(36%),替罗非班组23例中9例出血(39%),阿司匹林、氯吡格雷和替罗非班联合用药出血率高达42%。作者认为应用抗血小板聚集药物前钻孔较栓塞术后钻孔出血比例明显降低(23%VS 43%),建议栓塞前行钻孔引流术。而kim等[3]报破裂动脉瘤支架辅助栓塞术中应用替罗非班共行10例脑室穿刺外引流术,5例栓塞前行钻孔,术后2例出现穿刺道出血(40%),5例栓塞后钻孔持续应用替罗非班未见穿刺道出血,同样Bruening等[4]8例钻孔引流中3例穿刺道出血,均为栓塞术前钻孔,建议栓塞后钻孔。

钻孔与栓塞孰前孰后均有穿刺道出血报道,本组病例替罗非班组术前钻孔1例,术后钻孔3例。氯吡格雷组均为术后即刻钻孔2例。2组即刻复查CT均未见穿刺道出血。但随后在双抗维持过程中替罗非班组出现2例穿刺道出血,1例为术前钻孔,1例术后钻孔,氯吡格雷组1例出现穿刺道出血。本组穿刺道出血均为少量出血,后自行吸收。多数报道[3,18-22]显示,应用抗血小板聚集药物钻孔引流穿刺道出血均为少量,血肿直径大多小于1.5 cm,绝大多数未引起任何临床症状,且后期可自行吸收。替罗非班应用前后组内比较血红蛋白下降具有统计学意义(P<0.001),而血小板计数下降无统计学意义(P=0.136),表明替罗非班抑制血小板聚集的同时,尽管稀释血液,但并未降低血小板数量。Chalouhi等[6]及Kim等[3]未发现替罗非班所致的血小板数目降低及皮肤瘀斑、泌尿道出血等症状。替罗非班组患者出院GOS≥4分比例为83.3%,氯吡格雷组为70.3%,替罗非班组有较好的预后率,尽管差异无统计学意义(P=0.187)。

本研究为单中心回顾性研究,并未对血小板功能进行监测,无法评估血栓、出血事件与血小板功能抑制率之间的联系,期待进一步多中心、前瞻性队列研究。与氯吡格雷相比,替罗非班在急性期支架辅助弹簧圈栓塞动脉瘤过程中并未增加梗塞及出血风险。能够有效抑制血小板同时并不增加出血风险,且能够溶解急性期新产生血栓,可作为急性期支架辅助弹簧圈栓塞动脉瘤抗血小板聚集的替代药物。

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Safety and efficacy of intravenous tirofiban and loading dose of clopidogrel in stent-assisted embolization of acute ruptured aneurysms

DONG An-shi,LIAO Xu-xing,ZHONG Wei-jian,LIU Xin-xin,ZHOU Si-jie,LIANG Ming-qin,LIN Haibo,LUO Jie,DENG Qi-jun
Department of Vascular and Interventional Neurosurgery,The First People"s Hospital of Foshan,Foshan,Guangdong province,528000,China

[Abstract] Objective To evaluate the safety and efficacy of intravenous tirofiban and loading dose of clopidogrel in stent-assisted coil embolization of acute ruptured aneurysms.Methods A retrospective analysis was made of the patients with ruptured intracranial aneurysms treated continuously from January 2012 to October 2018.All patients were treated with stent-assisted coil embolization in acute stage.Tirofiban was injected intravenously 15 minutes before stent release in tirofiban group,and clopidogrel was given a load dose of clopidogrel(300 mg)2 hours before stent release in clopidogrel group.The hemorrhage and thromboembolism events of two kinds of antiplatelet aggregation drugs were observed and analyzed.Results Thirty-eight ruptured aneurysms of 36 patients in tirofiban group were treated.Two patients(5.6%)had new thrombosis during operation,three patients(8.3%)had acute cerebral infarction after operation,two patients"(5.6%)aneurysms had ruptured during operation,and two patients had late hemorrhage after ventricular drilling and drainage.There was no significant difference in platelet count(P=0.136).Thirty cases with GOS score(≥4).In clopidogrel group,41 ruptured aneurysms were treated in 37 patients,2 patients(4.9%)had acute cerebral infarction after operation,2 patients"(4.9%)aneurysms had ruptured during operation,3 patients"(7.3%)aneurysms had ruptured after operation,and 1 patient had puncture bleeding after ventricular drilling and drainage.Platelet count decreased significantly(P=0.000).26 cases with GOS score(≥4).Conclusion Intravenous application of tirofiban during stentassisted coil embolization of ruptured aneurysms in acute phase showed lower ischemia and hemorrhage events.In particular,tirofiban can dissolve newly generated thrombus during operation,and can be used as an alternative drug for anti-platelet aggregation in perioperative period.

[Key words] tirofiban;ruptured aneurysm;stent;hemorrhage;thrombosis

doi: 10.3969/j.issn.1009-976X.2020.02.018

中图分类号:R654.3

文献标识码:A

基金项目: 广东省佛山市医学科技攻关项目(201308089;20151020138);佛山市医学科研立项课题(20080051);佛山市卫生和计生局医学科研课题(20170050);广东省佛山市“十三·五”医学重点专科基金(2016906);佛山市杰出青年医学人才基金(2018132)

作者单位:佛山市第一人民医院血管及介入神经外科,广东佛山528000

*通讯作者:廖旭兴,Email:drliao@126.com

Corresponding author:LIAO Xu-xing.drliao@126.com

(收稿日期:2019-11-18)

关键词: 破裂动脉瘤, 血栓, 替罗非班, 出血, 支架

CLC Number: