Peri-operative ASA plus clopidogrel did not significantly alter 30-day bleeding risk compared to ASA alone during carotid endarterectomy (OR 0.81; 95% CI 0.58-1.13; p=0.23).
Observational (n=12,317)
Yes
Does dual antiplatelet therapy compared to acetylsalicylic acid alone increase bleeding risk or reduce ischemic events in patients undergoing carotid endarterectomy?
In patients undergoing carotid endarterectomy, peri-operative dual antiplatelet therapy appears to have a similar safety and efficacy profile to single antiplatelet therapy.
Effect estimate: OR 0.81 (95% CI 0.58-1.13)
p-value: p=0.23
OBJECTIVE: Antithrombotic therapy is one of the cornerstones of the prevention of (recurrent) ocular or cerebral ischaemic events in patients with carotid artery stenosis. Randomised controlled trials on antithrombotic therapy for patients with minor ischaemic stroke and transient ischaemic attack (TIA) have recommended dual antiplatelet therapy (DAPT) in the three weeks following the index event. However, these trials excluded patients undergoing carotid revascularisation. To date, the optimal antithrombotic therapy during the peri-operative period of carotid endarterectomy (CEA) remains unclear. METHODS: Symptomatic and asymptomatic patients with carotid artery stenosis undergoing primary CEA from the Dutch Audit for Carotid Interventions registry between June 2013 and December 2020 were eligible for inclusion. The primary outcome was defined as post-operative cervical bleeding needing re-intervention or intracranial haemorrhage during the first 30 days following CEA. The secondary outcomes were ischaemic stroke or TIA or all cause mortality during the first 30 days following CEA. Descriptive statistics and multiple logistic regressions analyses were applied, with acetylsalicylic acid (ASA) as the reference value. RESULTS: A total of 12 317 patients were included. In the peri-operative phase, 31.0% of patients were treated with ASA, 32.4% with clopidogrel, 11.1% with ASA plus clopidogrel, 10.4% with ASA plus dipyridamole, 10.3% with vitamin K antagonist, and 4.8% with direct acting oral anticoagulants therapy. After multiple logistic regression analysis, no association was seen with the primary outcome in ASA plus clopidogrel (odds ratio OR 0.81; confidence interval CI 0.58 - 1.13; p = .23), and ASA plus dipyridamole (OR 0.69; CI 0.47 - 1.00; p = .059). Both the DAPT therapies were not associated with the secondary outcome. CONCLUSION: The effectiveness and safety of DAPT did not differ from single antiplatelet therapy (SAPT) in patients undergoing CEA and further evaluation is needed in prospective studies. Considering additional data from the literature and guideline recommendations, DAPT should be started immediately after stroke until 30 days after CEA followed by SAPT, due to a possible reduction in the risk of recurrence.
Donners et al. (Sat,) conducted a observational in Carotid artery stenosis (n=12,317). Dual antiplatelet therapy (ASA plus clopidogrel or ASA plus dipyridamole) vs. Acetylsalicylic acid (ASA) was evaluated on Post-operative cervical bleeding needing re-intervention or intracranial haemorrhage during the first 30 days following CEA (OR 0.81, 95% CI 0.58-1.13, p=0.23). Peri-operative ASA plus clopidogrel did not significantly alter 30-day bleeding risk compared to ASA alone during carotid endarterectomy (OR 0.81; 95% CI 0.58-1.13; p=0.23).