2024神经介入手术的抗血小板及抗凝治疗.docx

2024神经介入手术的抗血小板及抗凝治疗2023年，来自美国的StevenWHetts等对2014年神经介入外科学会神经介入手术中血小板功能抑制和血小板功能检测进行了更新。在血管内神经介入手术之前、期间和之后，抗血小板和抗血栓药物的管理仍在持续。同意以下建议：1 .在神经介入手术或大出血后，只要患者的血栓形成风险超过了出血风险，就可以恢复抗凝治疗。（I级，C-EO级）2 .血小板检测有助于指导临床实践，不同中心采用的阈值存在明显差异。（Ila级，B-NR级）3 .对于无合并症的接受脑动脉瘤治疗的患者，选择药物时除了考虑导管插入术和动脉瘤治疗装置的血栓风险外，不需要考虑其他因素。（11a级，B-NR级）4 .对于过去612个月内植入心脏支架的接受神经介入脑动脉瘤治疗的患者，推荐采用双重抗血小板治疗（DAPT）o（I级，B-NR级）5.对于3个月前发生过静脉血栓的患者，评估神经介入脑动脉瘤治疗时，如果延迟治疗动脉瘤有风险,应考虑停止口服抗凝（OAC）或维生素K拮抗剂。对于过去3个月内发生过静脉血栓，应考虑推迟神经介入手术。如果不可能，请参阅心房颤动指南。（11b级，C-LD级）6 .对于接受OAC并需要神经介入手术的心房颤动患者，应根据患者的缺血性和出血风险状况（IIa级，B-NR级），尽可能缩短三联抗栓治疗（OAC加DAPT）的持续时间或避免三联治疗，基于患者缺血和出血的风险，优选OAC加单联抗血小板治疗（SAPT）o7 .对于未破裂的脑动静脉畸形患者，没有指征需要改变因其他疾病制订的抗血小板或抗凝治疗方案（11b级，C-LD级）8 .症状性颅内动脉粥样硬化性疾病（ICAD）患者在神经介入治疗后应继续DAPT,以预防卒中复发。（11a级，B-NR级）9 .ICAD神经介入治疗后，DAPT应持续至少3个月。在没有新的卒中或短暂性脑缺血发作的情况下，可以根据患者的出血风险与缺血风险更改为SAPT。（11b级，C-LD级）10 .接受颈动脉支架术（CAS）的患者应在手术前接受DAPT,并在手术后至少持续3个月。（IIa级，B-R级）11 .对于急性大血管闭塞性缺血性卒中治疗期间进行CAS的患者，无论患者是否接受了溶栓治疗，给予负荷剂量的静脉或口服糖蛋白11b三a或P2Y12抑制剂，然后维持静脉输注或口服，以预防支架血栓形成，都是合理的。（11b类，C-LD）12 .对于脑静脉窦血栓形成患者，肝素抗凝是一线治疗；可以考虑血管内治疗，特别是药物治疗的情况下临床恶化的患者。（Ila级，B-R级）抗栓药物的转换及抗凝药物的逆转剂分别见表1、表2,表3为抗血小板药物的黑框警告，表4为择期神经介入手术的抗血小板和抗凝管理。表1抗栓药物的转换Table1HowtoswitchbetweendifferentanticoagulantsSwitchingbetweenagentsHowtoswitchCommentsVKAtoNOACOncetheINRis<2WhentransitioningfromoralVKAtonewdirectoralantkoaguiants(NOACs)inpatientswtx>cannotachieveconsistentINRNUFHtoNOAC2hoursafterstoppingUFHWhengoingfromWtooralIMWHtoNOACWeothenextdoseofLMWHwasdueWentransitioningfromIMWHtonewrectoralantkoagulant(NQACs)NOACtoVKAConcomitanttreatmentuntilINVU2to3IfpatientcannottolerateNOACordoesnothaveaccesstoitNOACtoUFH<xLMWHWenthenextdoseofNOACwasdueWhengoingfromnewdirectoralanticoagulant(NOACs)toparenteraladministrationOneNOACtoanotherNOACMenthenextdoseoffirstNOACwasdueWenswitchingbetweenoneNOACtoanotherNOACINR.intemationdlnormalizedratio;*antagonist.Mintravenous;LMWH.lowmolecularweightheparin;NOACvnoveloralanticoagulant;UFH.Unfractiondtedheparin;VKA.vitaminK表2抗凝药物的逆转剂Table2ReversalagentsforanticoagulantsAnticoagulantReversalagentHeparinProtaminesulfateLMWHProtaminesulfate(partialreversal)WarfarinVitaminKDabigatranIdarucizumabApixabanAndexanetalfaEdoxabanAndexanetalfaRivaroxaban(higherdoses)AndexanetalfaNodatashowthatfastreversalofadirectoralanticoagulantleadstoabetterclinicaloutcome.961.MWHilowmolecularweightheparin.表3抗血小板药物的黑框警告Table3'Blackboxwarning'(BBW)labelsforselectedantiplateletagentsDrugFDAinitialapprovalDateofBBWWdrnin9CIopkiOgreI(Ptom)November17,IWMarch12,2010Theeffectiveness&dopidogrdresultsfromitsantiplatdetactivity,wkdependentonhsconversionIoanactivemetabolitebytheCytOCbromeP450(CYP-4S0)system,principa*yCYP2C19.Clopidogreiatrecommendeddoeformsk»oftheactiveMaboiiteAndhaSareducedeffectonp½leHactivityinXtiCnbwhoareh0mQzy90(foenon-functonlalldno(theCYP2C19genes(trmed,CYP2C19poorm<sbMr)TcUareavailabletoidentifypatientsM)OareCYP2C19poocmetabdizen.ComderuseofanotherPUtdetP2Y12irbitocinpatientskielihedasCYP2C19poormeub02mDipyndafnoIeZASA(Aggrtnooi)November22.1999WA-Eptifibatide(IntegriIin)June8.2001NZA-PrMugrd(Eff()July10.2009My10.2009PrawgrHcancausesi9i6snlandSofnetifnftCaulbleeding.DonotmepfMu9rdinpatientswithactivepathologkalbleedingorahtslofyoftransientiscemkattackorstroke.Riskfactorsfoebleedingincludebodyweight<60kg,propensitytobd.andconcomitanteofmedicationsthatinm»etheriskofbleeding(eg,warfarin,heparin,fibnnolytk.ChronkuseofNSAIDs).PrasugrdKnotrecommended5patients7$years0f09e0roldnexceptfofhighEksituations(diabeteshloryofpriormyocardialin(arclk>).DonotSUrtp(M9reinPMient5IikdytoUndeVgour9t0tCABGanddcotinueM7<fajbeforeanywr9ery.Ifpossible*managebleedingwithoutdrontinuingPraSUgrUasdcontinuatk)ninthefirstfewweeksafteracutecoronafysyndromemaytneaserkforsubsequentCardbovasculareventsTicagrHoc(Brifinta)July20.2011July20.2011TkagrHoccancausesignificantsometimes½Ulbedrg.DonotuseinpatientswithactivePathoiOgkalbleedingorhistoryofintraanialhemorrhage.DonotstartinpatientsundergoingurgentCABG.IfPoSSIb他manegebleedingwithoutdcontinuingtk9rd0r.Sloppingtk49relorincreasesterkofsubsequentcrovMchrmnb.MainlenafKedo$c$o<Mpirinabove100mginZtienbwithoteCoronMysyndromereducetheeffectiveness“tkagrHorandshouldbeavoidedReference:httWMww.fdawdrgsru9safetyndaValIabdify/drugsafetycommunicationsAccessedNovember1.2O22.vASAaspi11aCABG,coronaryarteryM>a¼grafting;2A.USFoodandDrugAdministration;NSAKXnon-slefdalanti-inflammatorydrugs.表4择期神经介入手术的抗血小板和抗凝管理Table4AntiplateletandanticoagulationmanagementfewselectedneuroitervetionaltreatmentproceduresUnnipturedanerysmRupturedfuysntUnnipturedAVMtRupturedAVMiICADICASNocomocbkfttiesNone4UPTorDAnttNonetSAFlorDAPTNoneocSAPTNoneOAPTDARTCoronarystenVPCIDAFTSAPT心34monthspostKl.DAPTif<MmonthspostKlOAPTSAFTifJ-6monthspostKl.DAPTif<J-6monthspostKJDAPTDAPTAthfibriIUtionAC÷SAPTocAC*DARi;reaueumkat3monthWIrw$e»rnkst1monthACeSAFTorAOtmreaueumkM3monthsSAPT.rnkat1monthM.UPT<xM(MPlreauesrkl3monthsAC*SAHocAC*DAFlreaueumkat3monthsAcutesystemkvenousthrombosisAC*SAPTocAC÷OAnreassessriskat3monthsSAPT.considerIVCfilmm»e$Sriskat1monthAC÷SAPTocAC÷OA11reassessrkM3monthsSAPT.considerIVCfiltetrme$做at1monthAC÷SAPTocAC÷OAPlreassessriskM3mowtieAC*SAJ*TocAC÷DAPlreassessriskat3HowtometUble:IhwerecommendotkimarenotexhMtiwbutimtMdMemeantaa9tfwralapproach.MedkJtiorHrwedtobeMMduli2*dIoaPMtKgpatientUUngmuh>dtso0MymanagementeUnrupiuftdaneurysm(orrupturedaneutym±14daysafterrup(ur«)<dudbngcoding(SAPT),bdNooo-assBiedcoiling(SA11),Sttntassisied4ng(DAPT)1HoMHftwnmgSlent(DAPTiKitra-WccubrAowdnruption(IXART).tptufedawysm(<14daysafterrupture)<ludgCoding(none).MlOorVaSXedcotog(none),st*t-asss*edcoiling(proceduralIVQAPTconvertedtooralDAPTWlthln24hours')H0w<(fiwrtm9Uent(procedureIVOAPTwvttdtoorJDAPTWiM24hM11hintrMMcUMllwdiruption(noneorSAPT).Noteth>topenwr9frymaybePrtfefabktondovcubrtherapyforaneu11rsrmamenableIosuriIheQPygiventhecomplexityofant)pUteletmanagefnentGpatentswithrupturedaeuryymwhomayalsoneedextraVCntnCUUrdramPldCefnem.iUnru(urdAVMMUdngIranurterolortrMtswnomr>-BCA.EVOH.ortaMaM>n.§RUPtUredAVM-includingtrma11efUIortrwwfxnBCEVOH.orcoilembofczdtion.Hlntraoamalathero¼ierocdisease(KAD)mdudngangioplastyJrKyOCstenting.evCarotadarteryStfnting(CAS>-<ndudtnggioUtyandstenting.ttSeeaho2014SNISGtMMineHOM>elMX2020''AC,an(>>agubt)c<AVM.arteriovenousmKoatnn;DAHdualvtipUCete<therapy(usuallyaspirinp¼ano(cvage<nEVOH,elhylmewylkoholcopomerZintravenous；IVCinnorVend5Kr>BCA.n-butylCyan(UCryhte;PCI.percutaneousxofuryote<venUon;SAPT.SmgIeatblettherapy(uwatyaspnnmonotherapy).文献来源：ClemensMSchirmer,KetanRBulsara,FawazAl-Muftizetal.Antiplateletsandantithromboticsinneurointerventionalprocedures:GuidelineupdateJ.NeurointervSurgz2023z15(11):1155-1162.