Safety and efficacy of emergent dual antiplatelet therapy after carotid stenting in acute ischemic stroke with tandem lesions

Background: Optimal periprocedural antithrombotic management after emergent carotid artery stenting (eCAS) for acute ischaemic stroke (AIS) due to atherothrombotic tandem lesions (TL) remains controversial. Methods: Population-based observational study in Catalonia (Spain), including adult AIS patients with atherothrombotic TL treated with endovascular treatment and eCAS (January 2017–March 2023). Emergent dual antiplatelet therapy (DAPT) was compared with other regimens (single or no antiplatelet therapy). The primary outcome was a composite of sICH (symptomatic intracranial haemorrhage) and 30-day mortality. Secondary outcomes included any haemorrhagic transformation (HT), the ordinal shift in 90-day modified Rankin Scale (mRS) score and acute stent thrombosis within 72 hours, adjusted with inverse probability of treatment weighting. Results: Among 297 patients (mean age 70.6±10.3 years), 86 (29.0%) received emergent DAPT. The composite outcome occurred less frequently in the DAPT group (10.5% vs. 25.6%), aOR 0.41 (95% CI 0.18-0.94, p=0.035). The DAPT group showed better 90-day functional outcome in the adjusted shift analysis (commonOR 1.94, 95% CI 1.19–3.15, p=0.008), without differences in overall HT (aOR 0.71, 95% CI 0.37-1.34, p=0.291) and stent thrombosis rate (10.5% vs 7.1%, p=0.336, insufficient events for adjusted analysis). Among patients receiving DAPT within 24 hours, outcomes did not differ according to whether it was initiated emergently or deferred. Conclusions: Emergent DAPT during eCAS resulted in a lower rate of the composite outcome (sICH and 30-day mortality) and better 90-day functional outcome, without differences in stent thrombosis or overall HT rate. These findings support the safety of emergent DAPT after eCAS, although residual confounding cannot be excluded.