Bivalirudin as a substitute for heparin in neurointervention for patients with heparin-induced thrombocytopenia

• Published in: Journal of stroke and cerebrovascular diseases Vol. 33; no. 6; p. 107310
• Main Authors: Sukumaran, Madhav, Cantrell, Donald R., D'Agostino, Carly, Jahromi, Babak S., Ansari, Sameer A., Potts, Matthew B.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.06.2024
• Subjects: Aneurysm coiling; Aneurysm, False - drug therapy; Aneurysm, False - surgery; Aneurysm, Ruptured - diagnostic imaging; Aneurysm, Ruptured - surgery; Anticoagulants - adverse effects; Antithrombins - adverse effects; Antithrombins - therapeutic use; Bivalirudin; Drug Substitution; Endovascular neurosurgery; Endovascular Procedures - adverse effects; Heparin - adverse effects; Heparin-induced thrombocytopenia; Hirudins; Humans; Intracranial Aneurysm - drug therapy; Intracranial Aneurysm - surgery; Male; Middle Aged; Neurointervention; Peptide Fragments - adverse effects; Peptide Fragments - therapeutic use; Recombinant Proteins - administration & dosage; Recombinant Proteins - adverse effects; Recombinant Proteins - therapeutic use; Thrombocytopenia - chemically induced; Thrombocytopenia - diagnosis; Thrombocytopenia - drug therapy; Treatment Outcome; Aneurysm coiling; Bivalirudin; Endovascular neurosurgery; Neurointervention; Heparin-induced thrombocytopenia
• ISSN: 1052-3057; 1532-8511
• DOI: 10.1016/j.jstrokecerebrovasdis.2023.107310

•Heparin-induced thrombocytopenia results from heparin exposure and can be life-threatening.•Bivalirudin can substitute for heparin in patients with heparin-induced thrombocytopenia.•Bivalirudin can substitute for heparin in neuroendovascular interventions. Heparin-induced thrombocytopenia is a known complication of heparin exposure with potentially life-threatening sequelae. Direct thrombin inhibitors can be substituted for heparin in patients with heparin-induced thrombocytopenia that require anticoagulation. However, the use of direct thrombin inhibitors as a substitute for heparin has not been widely reported in the neuroendovascular literature. Here we report the first use of the direct thrombin inhibitor bivalirudin in a neuroendovascular procedure as a substitute for heparin in a patient with a ruptured pseudoaneurysm and heparin-induced thrombocytopenia, and review the literature on the use of bivalirudin and argatroban for such patients. Bivalirudin was safely and effectively used in the case reported, with no thrombotic or hemorrhagic complications. Our literature review revealed a paucity of studies on the use of heparin alternatives, including bivalirudin, in neuroendovascular procedures in patients with heparin-induced thrombocytopenia. Heparin-induced thrombocytopenia is an important iatrogenic disease process in patients undergoing neuroendovascular procedures, and developing protocols to diagnose and manage heparin-induced thrombocytopenia is important for healthcare systems. While further research needs to be done to establish the full range of anticoagulation options to substitute for heparin, our case indicates bivalirudin as a potential candidate.