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Safety and Effectiveness of Antiplatelet Loading during Transcarotid Artery Revascularization
Hanaa Dakour-Aridi, MD1, Mackenzie Madison, MD1, Shihuan K. Wang, MD2, Andres Fajardo, MD1, Michael P. Murphy, MD1, Marc L. Schermerhorn, MD3, Grace Wang, MD4, Jens Eldrup Jorgensen, MD5, Vikram Kashyap, MD6, Raghu L. Motaganahalli, MD1.
1Indiana University School of Medicine, Indianapolis, IN, USA, 2The University of Texas Health Science Center at Houston McGovern School of Medicine, Houston, TX, USA, 3Beth Israel Deaconess Medical Center, Boston, MA, USA, 4Hospital of the University of Pennsylvania, Philadelphia, PA, USA, 5Maine Medical Center, Portland, ME, USA, 6Meijer Heart and Vascular Institute, Corewell Health, Grand Rapids, MI, USA.

Objective: Prior studies have emphasized the importance of compliance with preoperative dual antiplatelet therapy (DAPT) in patients undergoing Transcarotid artery revascularization (TCAR). This investigation examines differences in perioperative outcomes following TCAR based on the timing of antiplatelet administration. Methods: Consecutive TCAR procedures from the Vascular Quality Initiative (2016-2022) were identified. Patients were divided into: 1) those on preoperative DAPT taken at least within 36 hours of the procedure (54.2%); 2) those on at least 1 antiplatelet who received a supplemental dose of another antiplatelet (aspirin or P2Y12 antagonist) within 4 hours before the procedure (32.5%); 3) Patient not on prior antiplatelets who received a loading dose on the day of the procedure (0.9%). Perioperative outcomes were compared between the 3 groups using univariable and multivariable analysis.
Results: A total of 22,310 patients were on DAPT (Group 1),13,392 were on at least one antiplatelet and received a supplemental dose (Group 2) and 361 patients received a loading dose on the day of the intervention (Group 3). Patients in Group 3 were older, more likely to be symptomatic, and had lower cardiac comorbidities. On univariable analysis, there was no significant difference in perioperative outcomes between the 3 groups (Table 1), except for increased rates of in-hospital restenosis/occlusion in group 3 (n=2, 0.6%), compared to group 1 (n=23, 0.1%) and group 2 (n=26, 0.2%) (P=0.01). After adjusting for baseline differences between the 3 groups, no significant association was observed between the groups and in-hospital stroke/death [Group 2 vs. 1: OR (95%CI: 1.03 (0.85-1.26), P=.74; Group 3 vs. 1, OR(95%CI): 1.22 (0.61-2.45), P=0.57) or bleeding complications [OR (95%CI): 1.07 (0.80-1.45) and 0.65 (0.25-1.70), respectively, P>0.05]. However, compared to patients on preoperative DAPT, patients in groups 2 and 3 had higher odds of stent stenosis/occlusion [Group 2: 1.92 (1.08-3.4), P=0.03; Group 3: 5.5 (1.3-23.7), P= 0.02]. No significant difference in 30-day adjusted outcomes was observed between the 3 groups.
Conclusions: This study demonstrates that administering loading or supplemental doses of antiplatelets to rapidly achieve therapeutic levels on the day of TCAR is feasible without an increase in perioperative stroke or bleeding complications.

Table 1. Crude Rates of In-Hospital and 30-day Outcomes Among the 3 Study Groups
DAPT (No Loading)Loading + Preop AntiplateletLoading onlyP-value
Death84 (0.4)53 (0.4)4 (1.1)0.09
Ipsilateral Stroke224 (1.0)151 (1.1)5 (1.4)0.45
Any Stroke259 (1.2)180 (1.3)5 (1.4)0.30
Myocardial Infarction (MI)120 (0.5)64 (0.5)1 (0.3)0.73
Stroke/Death315 (1.4)208 (1.6)8 (2.2)0.28
Stroke/Death/MI413 (1.9)264 (2.0)9 (2.5)0.51
Bleeding400 (1.8)280 (2.1)5 (1.4)0.11
Immediate Restenosis/Occlusion23 (0.1)26 (0.2)2 (0.6)0.01
Return to OR136 (0.6)98 (0.7)2 (0.6)0.37
Thirty days (n=22,718)
Stroke276 (2.5)194 (2.45)5 (2.5)0.95
Death166 (1.4)121 (1.5)5 (2.4)0.42
Stroke/death406 (3.6)281 (3.5)9 (4.5)0.66
High-grade restenosis63 (0.7)62 (1.0)00.11

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