We thank Drs Schirmer, Hoit, and Malek for their interest in our article. They are quite correct in pointing out that the Amplatzer vascular plug is porous, with an associated potential for downstream thromboembolic events during the interval between initial deployment of the plug and cessation of flow. However, the coils that they used in tandem with the vascular plugs in their reported cases1 were also porous and presented a similar risk. Some practitioners advocate upstream temporary balloon occlusion during parent vessel occlusion with coils to prevent such occurrences. We have no data that suggest this is necessary, but the practice makes intuitive sense. When antiplatelet agents are present, it is likely that more plugs or coils will be necessary to occlude the vessel. We maintain, however, that for patients receiving full heparin dose, provided other hemostatic parameters are normal and there are no antiplatelet agents on board, 2 properly sized Amplatzer vascular plugs will safely occlude most internal carotid or vertebral arteries. Detachable balloons or a “covered” plug definitely represent a better solution, but neither is available in the United States right now.
Reference
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