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Efficacy And Safety Of Variable Perioperative Antithrombotic Regimens In Patients Undergoing Carotid Endarterectomy
Jemin Park, MD1, Camila R. Guetter, MD, MPH
1, Jeremy D. Darling, MD
1, Isa F. van Galen, MD
1, Michael A. Ciaramella, MD
1, Chun Li, MD, MPH
2, Jeffrey Jim, MD
3, Marc L. Schermerhorn, MD
1, Christina L. Marcaccio, MD, MPH
1.
1Beth Israel Deaconess Medical Center, Boston, MA, USA,
2Medical University of South Carolina, Charleston, SC, USA,
3Allina Health Minneapolis Heart Institute, Minneapolis, MN, USA.
OBJECTIVES: Current SVS recommendations for perioperative antithrombotic therapy in patients undergoing CEA are limited. In acutely symptomatic patients, dual antiplatelet therapy (DAPT) is recommended for secondary stroke prevention. In asymptomatic patients, there are no clear recommendations, though single antiplatelet therapy with aspirin (ASA) is most commonly used. We examined the efficacy and safety of various perioperative antithrombotic regimens in patients who underwent CEA in the VQI.
METHODS: We retrospectively reviewed all patients who underwent CEA in VQI from January 2003 to September 2024. We stratified patients based on their pre-operative antiplatelet regimen: No-antiplatelet, ASA-only, Clopidogrel-only, DAPT (ASA/Clopidogrel), and Alternative-DAPT (ASA/Alternative P2Y12 Inhibitors). We created propensity scores for each treatment regimen and assessed in-hospital stroke/death and bleeding complications using inverse probability of treatment weighted log binomial regression, with ASA-only as the reference group and adjusting for intraoperative protamine use and drain placement. We also assessed outcomes stratified by preoperative symptom status.
RESULTS: Of 216,615 CEA patients: 54% received ASA-only, 11% No-antiplatelet, 6% Clopidogrel-only, 29% DAPT, and 1% Alternative-DAPT. The corresponding unadjusted rates of in-hospital stroke/death were 1.3%, 1.7%, 1.2%, 1.2%, and 1.6%. After adjustment, compared with ASA-only, in-hospital stroke/death was lower with Clopidogrel-only (RR 0.81, 95% CI 0.67-0.98) and DAPT (RR 0.79, 95% CI 0.72-0.87). In symptomatic patients (26% of the cohort), there was a trend towards lower in-hospital stroke/death with DAPT (RR 0.88, 95% CI 0.76-1.00). In asymptomatic patients, in-hospital stroke/death was lower with Clopidogrel-only (RR 0.70, 95% CI 0.53-0.92) and DAPT (RR 0.73, 95% CI 0.64-0.83). Bleeding complications were higher with DAPT (RR 1.49, 95% CI 1.35-1.66) and trended toward higher with Clopidogrel-only (RR 1.21, 95% CI 0.99-1.48) but were similar across other regimens (Table).
CONCLUSIONS: Compared to ASA-monotherapy, Clopidogrel-monotherapy and DAPT had lower rates of in-hospital stroke/death after CEA albeit with higher rates of bleeding complications, particularly with DAPT. Analyses in patients on alternative P2Y
12 inhibitors were limited by sample size; however, repeat analyses with a larger cohort will be valuable in the future. Overall, these findings support current guidelines but highlight the challenge in balancing stroke prevention and bleeding risk and suggest a role for individualized risk assessment.
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