Abstract:Objective Current carotid artery stenting practice guidelines recommend dual antiplatelets to reduce major adverse cardiovascular events during and after transcarotid revascularization (TCAR). However, some patients are poor candidates for this regimen, due to preexisting need for anticoagulation, allergies, and/or risk of major bleeding. Therefore, this investigation was performed to review outcomes associated with patients undergoing TCAR while on alternative medication regimens to determine safety and effic… Show more
“…We found stroke (2.2% vs 2.8%, P = 0.58) and death (1.3% vs 1.1%, P > 0.99) to be similar at 30 days but mortality increased (5.4% vs 13.5%, P = 0.02) at a mean of 25.4 and 29.1-months postprocedure in the alternative medication cohort. 11 Unfortunately, this study was not likely adequately powered to detect a difference between groups, so we elected to examine the influence of antiplatelet choice in VQI, a large, nationally representative database with access to detailed patient-specific data.…”
Objective:
To define the risks associated with the replacement of dual antiplatelets for alternate medication regimens.
Background:
Patients undergoing transcarotid artery revascularization (TCAR) for atherosclerotic disease in the Vascular Quality Initiative database from September 2016 to June 2022 were included. In all, 29,802 TCAR procedures were captured between 2016 and 2022, consisting of 24,651 (82.7%) maintained on dual antiplatelet therapy (DAPT) and 5151 (17.3%) on alternative regimens.
Methods:
Patients maintained on DAPT were compared with those on alternative regimens consisting of any combination of single antiplatelet monotherapy and/or anticoagulation.
Results:
On univariable analysis, patients on alternative medications were more likely to experience in-hospital death, ipsilateral stroke, any stroke, and transient ischemic attacks compared with patients in the DAPT group. The mortality rate was higher at 1 year in the alternative cohort (4.7% vs 7.0%, P<0.01). The use of alternate medication regimens was associated with increased odds of stroke and the composite outcome of in-hospital stroke/death compared with DAPT. There was also a significant association between alternative medication use and increased odds of in-hospital transient ischemic attack, immediate stent occlusion, and return to the operating room. At 1 year, there was no significant difference in the incidence of stroke between the 2 groups. However, the use of alternate regimens was associated with higher 1-year of mortality after multivariable adjustment.
Conclusions:
Patients not maintained on DAPT after TCAR experienced an increased risk of stroke and death in the perioperative and follow-up periods. Increased surgeon vigilance is required to ensure compliance with dual antiplatelets as recommended.
“…We found stroke (2.2% vs 2.8%, P = 0.58) and death (1.3% vs 1.1%, P > 0.99) to be similar at 30 days but mortality increased (5.4% vs 13.5%, P = 0.02) at a mean of 25.4 and 29.1-months postprocedure in the alternative medication cohort. 11 Unfortunately, this study was not likely adequately powered to detect a difference between groups, so we elected to examine the influence of antiplatelet choice in VQI, a large, nationally representative database with access to detailed patient-specific data.…”
Objective:
To define the risks associated with the replacement of dual antiplatelets for alternate medication regimens.
Background:
Patients undergoing transcarotid artery revascularization (TCAR) for atherosclerotic disease in the Vascular Quality Initiative database from September 2016 to June 2022 were included. In all, 29,802 TCAR procedures were captured between 2016 and 2022, consisting of 24,651 (82.7%) maintained on dual antiplatelet therapy (DAPT) and 5151 (17.3%) on alternative regimens.
Methods:
Patients maintained on DAPT were compared with those on alternative regimens consisting of any combination of single antiplatelet monotherapy and/or anticoagulation.
Results:
On univariable analysis, patients on alternative medications were more likely to experience in-hospital death, ipsilateral stroke, any stroke, and transient ischemic attacks compared with patients in the DAPT group. The mortality rate was higher at 1 year in the alternative cohort (4.7% vs 7.0%, P<0.01). The use of alternate medication regimens was associated with increased odds of stroke and the composite outcome of in-hospital stroke/death compared with DAPT. There was also a significant association between alternative medication use and increased odds of in-hospital transient ischemic attack, immediate stent occlusion, and return to the operating room. At 1 year, there was no significant difference in the incidence of stroke between the 2 groups. However, the use of alternate regimens was associated with higher 1-year of mortality after multivariable adjustment.
Conclusions:
Patients not maintained on DAPT after TCAR experienced an increased risk of stroke and death in the perioperative and follow-up periods. Increased surgeon vigilance is required to ensure compliance with dual antiplatelets as recommended.
“…Resistance to antiplatelet medications was not routinely tested at the University of Texas at Houston and performed on was a case-by-case basis at Indiana University, at the discretion of the operator. 11 We avoided “triple therapy” due to perceived bleeding risk, unless it was requested by the patient’s hematologist or cardiologist.…”
Introduction Carotid revascularization in patients with end-stage renal disease (ESRD) continues to be a controversial topic, as life expectancy is poor, thus, preventing the recouperation of cumulative stroke-risk reduction in the postoperative period. We performed this primarily descriptive analysis of the results of transcarotid revascularization (TCAR) in renal failure patients. Methods A retrospective review of two independent carotid revascularization databases maintained at two large health systems were performed to capture all consecutive TCAR procedures. Patients were classified as either (1) ESRD or (2) preserved renal function (PRF) and compared with standard univariate techniques, where appropriate. Results From December 2015 to April 2022, 851 consecutive TCARs were attempted at our participating facilities. Of these, 27 were performed in ESRD patients (all hemodialysis). These patients were younger and presented with a higher Charlson Comorbidity Index. The incidence of a high anatomic risk criterion as defined for the Centers for Medicare and Medicaid Services (CMS) were similar between groups, as was the incidence of a symptomatic carotid lesion. There were no differences between the groups in terms of intraoperative characteristics and the postoperative medication management were grossly similar by renal function. In the 30-day perioperative period, there were no stroke, death, or myocardial infarction in the 27 ESRD patients treated with TCAR. The mean duration of follow-up in the ESRD cohort was 15.0 months. During this time, there was no ipsilateral stroke events, one contralateral stroke, and one MI. All 27 carotid stents remained patent during this period. Six patients perished after TCAR at a mean interval of 12.2 months after TCAR. Conclusion Survival is poor after carotid revascularization via the TCAR technique on intermediate follow-up. Careful patient selection is required to identify those who will survive to collect on the cumulative stroke-risk reduction afforded by carotid intervention.
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