Outcomes of Patients on Triple Antithrombotic Therapy versus Single Antiplatelet Therapy Plus Anticoagulants Following Carotid Artery Stenting with Emphasis on Ticagrelor

Objectives Carotid artery stenting (CAS) is a well-established intervention for patients with carotid artery disease. The standard post-procedural regimen is dual antiplatelet therapy (DAPT) for at least four weeks. However, patients on chronic anticoagulation (AC) who undergo CAS and receive concomitant DAPT are believed to be at increased risk for major bleeding events. The optimal antithrombotic strategy in this population is controversial and outcomes of ticagrelor with AC have not been investigated. Our study aimed to evaluate adverse outcomes associated with triple therapy (TT) versus SAPT when combined with AC, specifically when ticagrelor was utilized. By doing so, we sought to assess the feasibility of shifting towards ticagrelor as a SAPT agent combined with AC to potentially reduce bleeding complications. We hypothesized that SAPT plus AC would provide thrombotic protection comparable to triple therapy while reducing bleeding complications and that ticagrelor-based therapy may represent a safe individualized alternative. Methods This retrospective, single-institution study spanning nine years evaluated clinical outcomes in patients undergoing CAS who received either AC plus DAPT or AC plus SAPT. Patients were grouped by antithrombotic regimen, with additional subgroup analyses focusing on ticagrelor-based triple and double therapy. Thirty-day outcomes included minor and major bleeding events, ischemic and hemorrhagic stroke, myocardial infarction and all-cause mortality. Platelet reactivity units (PRUs) were recorded preoperatively, postoperatively and at follow-up. The study was approved by the institutional review board. Results Of 491 patients undergoing CAS, 85 met inclusion criteria: 33 received TT and 52 received AC + SAPT. Among TT patients, 15 received ticagrelor; three experienced major complications (anemia requiring transfusion, upper GI bleed requiring embolization, and hemorrhagic stroke). Among the remaining 18 in the TT group (no ticagrelor), four complications occurred (anemia requiring transfusion; GI bleed requiring medication cessation, stent thrombosis with ischemic stroke, and hemorrhagic stroke). Of the AC + SAPT group, 20 patients received ticagrelor and two complications occurred (retroperitoneal hematoma and subdural hematoma). Among the remaining 32 patients on SAPT with AC (no ticagrelor), four complications were observed (two GI bleeds requiring embolization, one retroperitoneal hematoma and one unrelated death) Conclusions In patients on chronic AC undergoing CAS, adding DAPT is common but may increase adverse events. Our preliminary experience suggests that SAPT with AC does not raise the risk of stent thrombosis or stroke and may reduce bleeding. Multi-center studies are needed to further evaluate the safety of ticagrelor as a single antiplatelet agent in this population.