Dual Antiplatelet Therapy Prior to Expedited Carotid Surgery Reduces Recurrent Events Prior to Surgery without Significantly Increasing Peri-operative Bleeding Complications

Batchelder, Andrew; Hunter, Justin L.; Cairns, V.; Sandford, R.M.; Munshi, Ajay; Naylor, A.R.

doi:10.1016/j.ejvs.2015.07.019

Cited by 65 publications

(29 citation statements)

References 28 publications

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“…13 The protective neurologic effects of clopidogrel have also been suggested for urgent CEA 14 and in other series of patients with symptomatic carotid stenosis. 15,16 Furthermore, emerging evidence by Batchelder et al 17 suggests that initiating clopidogrel in patients who have recently suffered a TIA associated with 50% to 99% carotid artery stenosis can significantly reduce the risk of recurrent neurologic events before definitive CEA, thus recommending its use in this presumptively vulnerable patient population.…”

Section: Discussionmentioning

confidence: 99%

“…In addition to the clearly demonstrated protective perioperative neurologic effects independent of symptom status, we recommend dual therapy in symptomatic patients to reduce the risk of preoperative stroke after initial symptoms, as others have shown. 17 We also recommend meticulous attention to hemostasis when performing CEA in patients on dual therapy due to the increased risk of reoperation for bleeding.…”

Section: Discussionmentioning

confidence: 99%

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Dual antiplatelet therapy reduces stroke but increases bleeding at the time of carotid endarterectomy

Jones¹,

Goodney

Conrad

et al. 2016

Journal of Vascular Surgery

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Objective Controversy persists regarding the perioperative management of clopidogrel among patients undergoing carotid endarterectomy (CEA). This study examined the effect of preoperative dual antiplatelet therapy (aspirin and clopidogrel) on in-hospital CEA outcomes. Methods Patients undergoing CEA in the Vascular Quality Initiative were analyzed (2003–2014). Patients on clopidogrel and aspirin (dual therapy) were compared with patients taking aspirin alone preoperatively. Study outcomes included reoperation for bleeding and thrombotic complications defined as transient ischemic attack (TIA), stroke, or myocardial infarction. Secondary outcomes were in-hospital death and composite stroke/death. Univariate and multivariable analyses assessed differences in demographics and operative factors. Propensity score-matched cohorts were derived to control for subgroup heterogeneity. Results Of 28,683 CEAs, 21,624 patients (75%) were on aspirin and 7059 (25%) were on dual therapy. Patients on dual therapy were more likely to have multiple comorbidities, including coronary artery disease (P < .001), congestive heart failure (P < .001), and diabetes (P < .001). Patients on dual therapy were also more likely to have a drain placed (P < .001) and receive protamine during CEA (P < .001). Multivariable analysis showed that dual therapy was independently associated with increased reoperation for bleeding (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.20–2.42; P = .003) but was protective against TIA or stroke (OR, 0.61; 95% CI, 0.43–0.87; P = .007), stroke (OR, 0.63; 95% CI, 0.41–0.97; P = .03), and stroke/death (OR, 0.66; 95% CI, 0.44–0.98; P = .04). Propensity score matching yielded two groups of 4548 patients and showed that patients on dual therapy were more likely to require reoperation for bleeding (1.3% vs 0.7%; P = .004) but less likely to suffer TIA or stroke (0.9% vs 1.6%; P = .002), stroke (0.6% vs 1.0%; P = .04), or stroke/death (0.7% vs 1.2%; P = .03). Within the propensity score-matched groups, patients on dual therapy had increased rates of reoperation for bleeding regardless of carotid symptom status. However, asymptomatic patients on dual therapy demonstrated reduced rates of TIA or stroke (0.6% vs 1.5%; P < .001), stroke (0.4% vs 0.9%; P = .01), and composite stroke/death (0.5% vs 1.0%; P = .02). Among propensity score-matched patients with symptomatic carotid disease, these differences were not statistically significant. Conclusions Preoperative dual antiplatelet therapy was associated with a 40% risk reduction for neurologic events but also incurred a significant increased risk of reoperation for bleeding after CEA. Given its observed overall neurologic protective effect, continued dual antiplatelet therapy throughout the perioperative period is justified. Initiating dual therapy in all patients undergoing CEA may lead to decreased neurologic complication rates.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Dual antiplatelet therapy reduces stroke but increases bleeding at the time of carotid endarterectomy

Jones¹,

Goodney

Conrad

et al. 2016

Journal of Vascular Surgery

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“…The frequency of neurological events prior to CEA declined from 29 to 2.5% after implementation of a “best medical therapy” protocol. A study from the UK also found that in patients with symptomatic carotid stenosis, dual antiplatelet therapy reduced the number of brain microemboli detected with TCD 18 . This study also found that 0 out of 100 patients awaiting CEA experience a recurrent stroke while awaiting revascularization.…”

Section: Symptomatic Carotid Stenosismentioning

confidence: 94%

Trends and controversies in carotid artery stenosis treatment

Lalla

Raghavan

2020

F1000Res

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Despite the completion of several multi-center trials, the management of carotid stenosis remains in flux. Key questions include the role of intensive medical management in the treatment of asymptomatic carotid stenosis. In addition, identification of patients with symptomatic stenosis who will most benefit from carotid revascularization remains a priority. The role of newer imaging techniques such as carotid plaque analysis with magnetic resonance imaging is also challenging current treatment paradigms. These topics are explored in this topical update.

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“…49 Specific to carotid disease, it has been shown that initiation of DAPT in patients with recently symptomatic carotid stenosis leads to decreased transcranial Doppler-detected microembolization (which are associated with TIA/Stroke risk) 50 , and recurrent neurological events. 51 Early initiation of DAPT should be considered after symptom onset, though this must be weighed against bleeding risk of any planned revascularization. 4, 52…”

Section: Developments and Controversies In Symptomatic Carotid Smentioning

confidence: 99%

Trials and Frontiers in Carotid Endarterectomy and Stenting

Jones

Brott

Schermerhorn

2018

Stroke

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Dual Antiplatelet Therapy Prior to Expedited Carotid Surgery Reduces Recurrent Events Prior to Surgery without Significantly Increasing Peri-operative Bleeding Complications

Abstract: Early introduction of dual antiplatelet therapy was associated with a significant reduction in recurrent neurological events and spontaneous embolization prior to CEA, without incurring a significant increase in major peri-operative bleeding complications.

Cited by 65 publications

References 28 publications

Dual antiplatelet therapy reduces stroke but increases bleeding at the time of carotid endarterectomy

Dual antiplatelet therapy reduces stroke but increases bleeding at the time of carotid endarterectomy

Trends and controversies in carotid artery stenosis treatment

Trials and Frontiers in Carotid Endarterectomy and Stenting

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