Carotid Restenosis Following Endarterectomy in Patients Managed With Single Antiplatelet Therapy Versus Dual Antiplatelet Therapy

Abstract

Background: Antiplatelet therapy is a cornerstone in the management of carotid artery disease following carotid endarterectomy (CEA). There is a paucity of data regarding the effect of dual antiplatelet therapy (DAPT) on restenosis rates. Methods: A retrospective review of patients who underwent CEA from January 1, 2007 to December 31, 2013 was performed at a single center. Study groups consisted of subjects who received DAPT and those who received single antiplatelet therapy (SAPT) following CEA. Restenosis was evaluated by carotid duplex. Severity and timing of restenosis, postoperative complications, and reinterventions were compared between study groups. Results: Between January 1, 2007 and December 31, 2013, 1453 patients underwent CEA. The SAPT group consisted of 245 patients and the DAPT group consisted of 1208 patients. No difference in restenosis was identified between groups at less than 6 weeks (6.5% vs. 11.7% 50-79% stenosis, 0% vs. 2.2% 80-99% stenosis, 2.2% vs. 0.6% occlusion, p = 0.368), and 6 weeks to 2 years (20.6% vs. 17.9% 50-79% stenosis, 1.1% vs. 1.0% 80-99% stenosis, 1.6% vs. 0.4% occlusion, p = 0.242). A higher rate of restenosis in SAPT was found greater than 2 years from surgery (68.4% vs. 82.4% <50% stenosis, 29.9% vs. 16.1% 50-79% stenosis, 0% vs. 0.6% 80-99% stenosis, 1.7% vs. 0.9% occlusion p = 0.004). This finding persisted on multivariable analysis with 31.6% of the SAPT group showing >50% stenosis vs. 17.6% of the DAPT group (adjusted OR 0.48, 95% CI 0.30-0.76, p = 0.002). In a propensity matched-population, 32.7% of the SAPT group demonstrated restenosis vs. 13.7% of the DAPT group (adjusted OR 0.35, 95% CI 0.16-0.77, p = 0.009). There was no difference in the need for reintervention between study groups (DAPT 3.8% vs SAPT 3.3%, p = 0.684). Conclusion: Following CEA, patients on DAPT exhibited lower rates of late restenosis. Despite this finding, a clinical difference in reintervention was not found during this study period.

Risk Factors for Carotid Restenosis in Patients After Eversion Endarterectomy vs Stenting: A Single-Center Experience

“…Our findings regarding dual antiplatelet therapy in patients with eCEA in lowering the risks of restenosis are similar to those of Glotzer et al 38 and Barboza et al 39 However, the effects of dual antiplatelet therapy on the incidence of carotid restenosis are still to be confirmed in prospective studies, and in the majority of patients, single antiplatelet therapy may be enough.…”

One month follow-up of carotid endarterectomy with in-hospital preoperative aspirin monotherapy and postoperative dual antiplatelet therapy in asymptomatic and symptomatic patients: A multi-center study

“…The perioperative and follow-up results revealed that the risk for stroke or death was lower in our patients (1.6 %) than in those without perioperative antiplatelet therapy (2.0 %) in a recent study [ 14 ]. Moreover, consistent with several previous studies, DAPT after surgery was associated with a low risk for postoperative death [ 10 , 24 ]. One patient, 65 years of age, with severe COPD and a history of major stroke died of pulmonary infectious complications that were not associated with the study treatment.…”

Discharge prescription patterns for antiplatelet and statin therapy following carotid endarterectomy: an analysis of the vascular quality initiative

“…A small, single-site study of 44 patients showed no increase in bleeding and less 30-day restenosis rates 29. Another single-centre larger study also found that DAPT was associated with lower rates of restenosis when compared with SAPT but this did not translate to any difference in reintervention rate 30. Our findings raise important questions into whether, after appropriate clinical re-evaluation, more patients could have been downgraded from preprocedure DAPT and the appropriateness of such a significant number of participants on SAPT being upgraded to DAPT.…”

“…29 Another single-centre larger study also found that DAPT was associated with lower rates of restenosis when compared with SAPT but this did not translate to any difference in reintervention rate. 30 Our findings raise important questions into whether, after appropriate clinical re-evaluation, more patients could have been downgraded from preprocedure DAPT and the appropriateness of such a significant number of participants on SAPT being upgraded to DAPT. Future studies need to determine how different discharge APT regimens (single vs double) and changes in APT regiments (both upgrade and downgrade) impact outcomes.…”