Dual Antiplatelet Therapy After Carotid Artery Stenting: Trends and Outcomes in a Large National Database

BackgroundWhile dual antiplatelet therapy (dAPT) is standard of care following carotid artery stenting (CAS), the optimal dAPT regimen and duration has not been established.MethodsWe canvassed a large national database (IBM MarketScan) to identify patients receiving carotid endarterectomy (CEA) or CAS for treatment of ischemic stroke or carotid artery stenosis from 2007 to 2016. We performed univariable and multivariable regression methods to evaluate the impact of covariates on post-CAS stroke-free survival, including post-discharge antiplatelet therapy.ResultsA total of 79 084 patients diagnosed with ischemic stroke or carotid stenosis received CEA (71 178; 90.0%) or CAS (7906; 10.0%). After adjusting for covariates, <180 days prescribed post-CAS P2Y12-inhibition was associated with increased risk for stroke (<90 prescribed days HR=1.421, 95% CI 1.038 to 1.946; 90–179 prescribed days HR=1.484, 95% CI 1.045 to 2.106). The incidence of hemorrhagic complications was higher during the period of prescribed P2Y12-inhibition (1.16% per person-month vs 0.49% per person-month after discontinuation, P<0.001). The rate of extracranial hemorrhage was nearly six-fold higher while on dAPT (6.50% per patient-month vs 1.16% per patient-month, P<0.001), and there was a trend towards higher rate of intracranial hemorrhage that did not reach statistical significance (5.09% per patient-month vs 3.69% per patient-month, P=0.0556). Later hemorrhagic events beyond 30 days post-CAS were significantly more likely to be extracranial (P=0.028).ConclusionsIncreased duration of post-CAS dAPT is associated with lower rates of readmissions for stroke, and with increased risk of hemorrhagic complications, particularly extracranial hemorrhage. The potential benefit of prolonging dAPT with regard to ischemic complications must be balanced with the corresponding increased risk of predominantly extracranial hemorrhagic complications.

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Increased Rates of Hemorrhages after Endovascular Stroke Treatment with Emergency Carotid Artery Stenting and Dual Antiplatelet Therapy

Cerebrovascular Diseases ◽

10.1159/000512204 ◽

2021 ◽

pp. 1-9

Author(s):

Felix Hadler ◽

Raveena Singh ◽

Martin Wiesmann ◽

Arno Reich ◽

Omid Nikoubashman

Keyword(s):

Risk Factors ◽

Carotid Artery ◽

Antiplatelet Therapy ◽

Carotid Artery Stenting ◽

Dual Antiplatelet Therapy ◽

Stroke Treatment ◽

Systemic Thrombolysis ◽

Stroke Registry ◽

Increased Risk ◽

Arterial Thrombolysis

Background: While endovascular stroke treatment (EST) of large vessel occlusions in acute ischemic stroke (AIS) is proven to be safe and effective, there are subgroups of patients with increased rates of hemorrhages. Our goal was to identify risk factors for intracerebral hemorrhage and to assess whether acute carotid artery stenting (CAS) was associated with increased bleeding rates. Methods: We performed a retrospective analysis of our monocentric prospective stroke registry in the period from May 2010 to May 2018 and compared AIS patients receiving EST with (n = 73) versus without acute CAS (n = 548). Patients with intracranial stents, intra-arterial thrombolysis, or dissection of the carotid artery were excluded. Results: Parenchymal hemorrhage rates (PH2 according to the ECASS classification) and symptomatic hemorrhage (sICH) rates were increased in EST patients receiving CAS with odds being 6.3 (PH2) and 6.5 (sICH) times higher (PH2 17.8 vs. 3.3%, p < 0.001 and sICH: 16.4 vs. 2.9%, p < 0.001). Additional systemic thrombolysis with rtPA (IVRTPA) was no risk factor for cerebral hemorrhage (p = 0.213). Conclusion: AIS patients receiving EST with acute CAS and consecutive tirofiban or dual antiplatelet therapy suffered from an increased risk of relevant secondary intracranial bleeding. After adjusting for confounders, tirofiban and dual antiplatelet therapy were associated with higher bleeding rates.

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Subcutaneous Hematoma Associated with Manual Cervical Massage during Carotid Artery Stenting

Interventional Neuroradiology ◽

10.1177/159101991101700318 ◽

2011 ◽

Vol 17 (3) ◽

pp. 386-390 ◽

Cited By ~ 3

Author(s):

A. Tsurumi ◽

Y. Tsurumi ◽

M. Negoro ◽

K. Yokoyama ◽

M. Oheda ◽

...

Keyword(s):

Carotid Artery ◽

Antiplatelet Therapy ◽

Carotid Artery Stenting ◽

Dual Antiplatelet Therapy ◽

Anticoagulation Therapy ◽

Balloon Occlusion ◽

Cervical Region ◽

Manual Compression ◽

Stenotic Lesion ◽

Distal Side

We describe a patient with subcutaneous hematoma associated with manual cervical massage during carotid artery stenting. A 73-year-old man with left cervical carotid artery stenosis presented with left amaurosis fugax. We performed carotid artery stenting using distal embolic protection with balloon occlusion. Dual antiplatelet therapy was maintained in the periprocedural period and an anticoagulant agent was administered during the procedure. Because the aspiration catheter became entrapped by the stent, it did not reach the distal side of the stenotic lesion, and manual compression of the cervical region was therefore performed. Immediately afterwards, a subcutaneous hemorrhage occurred in the cervical region. There was no postoperative dyspnea due to enlargement of the hematoma, which was absorbed spontaneously. Cervical subcutaneous hematoma can occur in the cervical region due to cervical massage in patients who are receiving adjuvant antiplatelet therapy and anticoagulation therapy.

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The efficacy and safety of perioperative dual antiplatelet therapy with ticagrelor versus clopidogrel in carotid artery stenting

Journal of Vascular Surgery ◽

10.1016/j.jvs.2021.09.045 ◽

2021 ◽

Author(s):

Christina L. Marcaccio ◽

Priya B. Patel ◽

Patric Liang ◽

Vinamr Rastogi ◽

Lars Stangenberg ◽

...

Keyword(s):

Carotid Artery ◽

Antiplatelet Therapy ◽

Carotid Artery Stenting ◽

Dual Antiplatelet Therapy ◽

Efficacy And Safety

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Serial Changes of Circulating Platelet Activation Markers after Carotid Artery Stenting

Angiology ◽

10.1177/0003319708321103 ◽

2008 ◽

Vol 60 (4) ◽

pp. 427-430 ◽

Cited By ~ 3

Author(s):

Fang Liu ◽

Jin Li ◽

Da-Ming Wang ◽

Jia-Chun Liu ◽

Yi-Ning Huang

Keyword(s):

Flow Cytometry ◽

Carotid Artery ◽

Antiplatelet Therapy ◽

Platelet Activation ◽

Carotid Artery Stenting ◽

Dual Antiplatelet Therapy ◽

Activation Markers ◽

Embolic Protection ◽

Protection Devices ◽

Platelet Aggregates

We investigated serial changes of circulation platelet activation markers in 40 patients undergoing carotid artery stenting under the protection of dual antiplatelet therapy and filter devices. Monocyte-platelet aggregates and PAC-1 (a marker specific for activated glycoprotein IIb/IIIa) analyzed by flow cytometry were determined in patients with symptomatic stenosis undergoing elective carotid artery stenting. Blood samples were obtained immediately before stent implantation and 0.5 hours, 18 hours, and 6 days after the procedure, respectively. All patients were already on dual antiplatelet therapy of aspirin and clopidogrel before carotid artery stenting, and all were stented with embolic protection devices. Both circulation monocyte-platelet aggregates and PAC-1 did not change significantly at the various time points after the procedure. Serial changes of monocyte-platelet aggregates and PAC-1 analyzed by flow cytometry fail to indicate the occurrence of platelet activation after carotid artery stenting under the treatment with dual antiplatelet therapy before carotid artery stenting and the application of embolic protection devices during the procedure.

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Three cases of dual antiplatelet therapy resistance in patients undergoing carotid artery stenting and stent assisted coil embolization

Journal of the Neurological Sciences ◽

10.1016/j.jns.2017.08.1750 ◽

2017 ◽

Vol 381 ◽

pp. 621

Author(s):

K. Miki ◽

Y. Yoshino ◽

K. Jun ◽

N. Shigeru

Keyword(s):

Carotid Artery ◽

Antiplatelet Therapy ◽

Coil Embolization ◽

Carotid Artery Stenting ◽

Dual Antiplatelet Therapy ◽

Therapy Resistance

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Postinterventional microembolism signals detected by transcranial Doppler ultrasound after carotid artery stenting

VASA ◽

10.1024/0301-1526/a000406 ◽

2015 ◽

Vol 44 (1) ◽

pp. 49-57 ◽

Cited By ~ 6

Author(s):

Michael Piorkowski ◽

Christina Kläffling ◽

Spiridon Botsios ◽

Christoph Zerweck ◽

Susanne Scheinert ◽

...

Keyword(s):

Logistic Regression ◽

Carotid Artery ◽

Antiplatelet Therapy ◽

Doppler Ultrasound ◽

Transcranial Doppler ◽

Carotid Artery Stenting ◽

Dual Antiplatelet Therapy ◽

Transcranial Doppler Ultrasound ◽

Lipid Lowering ◽

Lipid Lowering Therapy

Background: The occurrence of early post-procedural complications after carotid artery stenting (CAS) can be attributed to embolization of thrombus or plaque particles released from the stented segment. Vascular emboli can be non-invasively detected by transcranial Doppler ultrasound as microembolic signals (MES). We performed this study to discover factors predicting MES detected by transcranial Doppler (TCD)-monitoring within the early post-interventional phase. Patients and methods: In 134 consecutive patients undergoing CAS, transcranial Doppler monitoring of the ipsilateral middle cerebral artery was performed for MES detection during the first post-interventional hour. To identify clinical, morphologic, and procedure-related parameters likely to predict the occurrence of post-interventional MES a logistic regression analysis was performed. Results: In 134 patients (111 male, mean age 69.7 years) relevant MES were detected in 51 patients (38 %) with a median of 4 MES/h and a maximum of 62 MES/h. Three factors were observed to be associated with increased post-interventional MES-counts. These included symptomatic lesion (p < 0.05), elevated total cholesterol (p < 0.05), and aspirin monotherapy (p < 0.0005). In a binary logistic regression model, dual antiplatelet therapy (OR 5.6, p < 0.0005) and asymptomatic lesions (OR 2.6, p < 0.05) were revealed as independent predictors for the absence of post-interventional MES. Conclusions: Post-interventional MES were most likely in symptomatic lesions and patients with elevated cholesterol. The absence of an effective dual antiplatelet therapy and symptomatic lesions were revealed as independent predictors for post-interventional MES. An effective pre-interventional dual antiplatelet and lipid lowering therapy might improve the safety of CAS.

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