Dual antiplatelet therapy after carotid artery stenting: trends and outcomes in a large national database

2020 ◽  
Vol 13 (1) ◽  
pp. 8-13
Author(s):  
Eric S Sussman ◽  
Michael Jin ◽  
Arjun V Pendharkar ◽  
Benjamin Pulli ◽  
Austin Feng ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Carotid Artery ◽  
Antiplatelet Therapy ◽  
Carotid Artery Stenting ◽  
Dual Antiplatelet Therapy ◽  
National Database ◽  
Increased Risk ◽  
Hemorrhagic Complications ◽  
The Impact ◽  
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.

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

2020 ◽  
Vol 72 (3) ◽  
pp. 1144-1145
Author(s):  
E.S. Sussman ◽  
M. Jin ◽  
A.V. Pendharkar ◽  
B. Pulli ◽  
A. Feng ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Antiplatelet Therapy ◽  
Carotid Artery Stenting ◽  
Dual Antiplatelet Therapy ◽  
National Database ◽  
Large National Database

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

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

<b><i>Background:</i></b> 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. <b><i>Methods:</i></b> 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 (<i>n</i> = 73) versus without acute CAS (<i>n</i> = 548). Patients with intracranial stents, intra-arterial thrombolysis, or dissection of the carotid artery were excluded. <b><i>Results:</i></b> 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%, <i>p</i> &#x3c; 0.001 and sICH: 16.4 vs. 2.9%, <i>p</i> &#x3c; 0.001). Additional systemic thrombolysis with rtPA (IVRTPA) was no risk factor for cerebral hemorrhage (<i>p</i> = 0.213). <b><i>Conclusion:</i></b> 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.

P1187Pocket-Hematoma after cardiac implantable electronic devices surgery: a single centre study

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
L Spighi ◽  
F Notaristefano ◽  
R Annunziata ◽  
M D"ammando ◽  
G Zingarini ◽  
...  
Keyword(s):  
Antiplatelet Therapy ◽  
Antithrombotic Therapy ◽  
Pulse Generator ◽  
Dual Antiplatelet Therapy ◽  
Vitamin K Antagonists ◽  
Multivariate Regression Analysis ◽  
New Device ◽  
Increased Risk ◽  
The Impact ◽  
Pocket Hematoma

Abstract Intro Pocket hematoma is a common complication after pacemaker (PMK) or implantable cardioverter defibrillator (ICD) surgery. In this clinical setting anticoagulant and antiplatelet therapy are associated with an increased risk of hemorrhagic complications, but data are sparse. Purpose We examined  the impact of antiplatelet therapy and anticoagulation with vitamin K antagonists (VKA) or heparin on the risk of pocket hematoma. Materials and method: between august 2017 and june 2019, a total of 639 devices were implanted or replaced at our centre. Predictors of hematoma occurrence were determined by multivariate regression analysis. We used a specific definition of pocket hematoma: a) any palpable swelling in the pocket area requiring an unscheduled visit or prolonged hospitalization &gt; 24 h or re-hospitalization for hematoma, b) interruption of antithrombotics, c) reoperation, d) hemoglobin drop &gt; 2 g/dl or blood transfusion. The above criteria were assessed during hospitalization and up to 10 days after discharge. Results: the incidence of pocket hematoma was 7.5%. Among 639 patients (pts) including in the study 33.5% (214 pts) didn’ t take any antithrombotic therapy, 40.2 % (257 pts) were on single antiplatelet therapy (SAPT), 8.8 % (56 pts) were on dual antiplatelet therapy, 11.1 % (71 pts) were on uninterrupted VKA (mean INR 2). Heparin bridging was administered in 6.4% (41 pts). Ejection fraction (43 ±13 %) and  hemoglobin value before implantation (12.3 ±2.6 g/dL) in patients who developed hematoma were significantly lower compared with whose without hematoma. Patients with hematoma had a higher prevalence of congestive heart failure, ischemic cardiomyopathy and intake antithrombotic therapy. After adjusting for confounding factors with multivariate logistic regression only the use of dual antiplatelet therapy (OR 5.9 95% CI 1.5-21 p = 0.008) and the bridging with enoxaparin (OR 5.6 95% CI 1.4-22 p = 0.013) increased the risk of pocket hematoma. Single antiplatelet therapy (OR 2.6 95% CI 0.8-8.4 p = ns) and uninterrupted VKA (OR 0.9 95% CI 0.7-11 p = ns) did not increased the risk of pocket hematoma compared to no antithrombotic therapy. Pulse generator change and new device implant/upgrading (OR 1.8 95% CI 0.6-5.2 p = ns) carried the same haemorrhagic risk. Conclusion the use of DAPT or bridging with enoxaparin are highly predictive for the occurrence of perioperative pocket hematoma in patients scheduled for pmk/icd surgery. In contrast, single antiplatelet therapy and uninterrupted VKA  did not increase the risk of hematoma.

scholarly journals Impact of bleeding during dual antiplatelet therapy in patients with coronary artery disease

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Ying-Chang Tung ◽  
Lai-Chu See ◽  
Shu-Hao Chang ◽  
Jia-Rou Liu ◽  
Chi-Tai Kuo ◽  
...  
Keyword(s):  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
East Asian ◽  
Asian Population ◽  
Adverse Outcomes ◽  
Research Database ◽  
Coronary Syndrome ◽  
Asian Patients ◽  
Increased Risk ◽  
The Impact

AbstractThis nationwide retrospective cohort study used the National Health Insurance Research Database of Taiwan to compare the impact of bleeding on clinical outcomes in patients with acute myocardial infarction (AMI) versus chronic coronary syndrome (CCS). Between July 2007 and December 2010, patients with AMI (n = 15,391) and CCS (n = 19,724) who received dual antiplatelet therapy after coronary stenting were identified from the database. AMI was associated with increased risks of MI (AMI vs. CCS: 0.38 vs. 0.16 per 100 patient-months; p < 0.01), all-cause death (0.49 vs. 0.32 per 100 patient-months; p < 0.01), and BARC type 3 bleeding (0.22 vs. 0.13 per 100 patient-months; p < 0.01) at 1 year compared with CCS, while the risk of BARC type 2 bleeding was marginally higher in the CCS patients than in the AMI patients (1.32 vs. 1.4 per 100 person-months; p = 0.06). Bleeding was an independent predictor of MI, stroke, and all-cause death in this East Asian population, regardless of the initial presentation. Among the patients with bleeding, AMI was associated with a higher risk of ischemic events at 1 year after bleeding compared with CCS (MI: 0.34 vs. 0.25 per 100 patient-months; p = 0.06; ischemic stroke: 0.22 vs. 0.13 per 100 patient-months; p = 0.02). The 1-year mortality after bleeding was comparable between the two groups after propensity score weighting. In conclusion, bleeding conferred an increased risk of adverse outcomes in East Asian patients with AMI and CCS.

scholarly journals Subcutaneous Hematoma Associated with Manual Cervical Massage during Carotid Artery Stenting

2011 ◽  
Vol 17 (3) ◽  
pp. 386-390 ◽  
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.

Serial Changes of Circulating Platelet Activation Markers after Carotid Artery Stenting

Angiology ◽  
2008 ◽  
Vol 60 (4) ◽  
pp. 427-430 ◽  
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.

Three-Month Outcome of Carotid Artery Stenting in Patients with/without Coexistent Unruptured Intracranial Aneurysms

2020 ◽  
Vol 49 (4) ◽  
pp. 382-387
Author(s):  
Ximeng Yang ◽  
Jun Lu ◽  
Peng Qi ◽  
Junjie Wang ◽  
Shen Hu ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Carotid Artery ◽  
Carotid Artery Stenting ◽  
Intracranial Aneurysms ◽  
Dual Antiplatelet Therapy ◽  
Aneurysm Rupture ◽  
Unruptured Intracranial Aneurysms ◽  
Significant Difference ◽  
Symptomatic Intracranial Hemorrhage ◽  
Baseline Characteristics

Introduction: Safety of carotid artery stenting (CAS) in patients having carotid stenosis with coexistent unruptured intracranial aneurysms (UIAs) is rarely reported. Thus, we studied the 3-month outcome of CAS in the presence of coexistent UIAs in our institution. Methods: A retrospective analysis of patients receiving CAS at our institution from September 2011 to December 2019 was carried out. Patients were stratified into 2 groups: group of CAS with UIAs (CAS-UIA) and group of CAS without UIAs (CAS). The main complications within 3 months after stenting were TIA, ischemic stroke, symptomatic intracranial hemorrhage (sICH), rupture of UIAs, and death. The baseline characteristics and complications of the 2 groups were compared. Results: Five hundred fifty-six patients (CAS, n = 468; CAS-UIA, n = 88) were included and 604 stenting procedures were performed. More patients had hypertension in the CAS-UIA group (87.5 vs. 73.7%, p = 0.006). There was no significant difference in TIAs, ischemic stroke, sICH, and death within 3 months after stenting between the CAS and CAS-UIA groups. None of the 113 coexistent UIAs detected in 88 patients had aneurysm rupture within 3 months after CAS. Conclusions: In our large cohort of CAS patients, coexistent UIAs are not uncommon. Stenting of a carotid artery in the presence of coexistent UIAs could be conducted safely. Together with 3-month dual antiplatelet therapy, CAS did not increase the rupture risk of the coexistent UIAs within 3 months.

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