Plavix Versus Ticagrelor For Antiplatelet Therapy In Transcarotid Artery Revascularization (TCAR) In The Society For Vascular Surgery Vascular Quality Initiative
Ahmed K. Ghamraoui, DO, MS, Alireza Daneshpajouh, DO, Joseph J. Ricotta II, MD, MS.
Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL, USA.
OBJECTIVES: Antiplatelet drug resistance, termed high on-treatment platelet reactivity (HTPR), is associated with thromboembolic complications following stent implantation. With clopidogrel resistance present in up to 44-66% of patients, ticagrelor has emerged as a viable alternative to circumnavigate these complications due to decreased resistance rates. A previous single-institution study has demonstrated the safe and effective use of ticagrelor in patients undergoing transcarotid artery revascularization (TCAR) with dynamic flow reversal. However, large-scale comparisons between clopidogrel and ticagrelor in TCAR patients are needed to confirm the safety of ticagrelor outside of highly selected patients and providers.
METHODS: Data from patients enrolled in the Society for Vascular Surgery Vascular Quality Initiative undergoing TCAR with a preoperative dual antiplatelet therapy regimen consisting of aspirin in addition to either clopidogrel or ticagrelor for all date ranges prior to March 2020 were analyzed and compared. Multivariable logistic regression was used to evaluate the primary outcomes of in-hospital adverse neurological event (stroke/transient ischemic attack), major bleeding event, myocardial infarction (MI), and death while adjusting for baseline characteristics of the patients.
RESULTS: A total of 8608 patients underwent TCAR with a dual antiplatelet therapy regimen that included clopidogrel versus 234 patients with ticagrelor. Compared to clopidogrel, patients on ticagrelor were significantly more likely to have coronary artery disease (50.4% vs 69.7% [P = <.001]) and prior open or percutaneous coronary intervention (48.6% vs 87.6% [P = <.001]). The unadjusted rates of in-hospital adverse neurologic event, major bleeding, MI, and death were not statistically significant among both groups (1.7% vs 2.6% [P = .31], 3.0% vs 2.6% [P = .72], 0.6% vs 1.3% [P = .18], and 0.4% vs 0.9% [P = .24], respectively). After multivariable adjustment, these remained statistically insignificant.
CONCLUSIONS: Despite a substantially higher medical risk in patients undergoing TCAR with ticagrelor, in-hospital rates of adverse neurological events, major bleeding events, MI, and death were similar to that of clopidogrel. This confirms the safety of ticagrelor as part of adjunctive dual antiplatelet therapy for TCAR. Further prospective studies, and studies with larger sample sizes and longer follow-up will be needed to better examine any outcome differences in TCAR between these two medications.
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