PMID- 36581013 OWN - NLM STAT- MEDLINE DCOM- 20230425 LR - 20240502 IS - 1097-6809 (Electronic) IS - 0741-5214 (Print) IS - 0741-5214 (Linking) VI - 77 IP - 5 DP - 2023 May TI - Efficacy and safety of single versus dual antiplatelet therapy in carotid artery stenting. PG - 1434-1446.e11 LID - S0741-5214(22)02713-6 [pii] LID - 10.1016/j.jvs.2022.12.034 [doi] AB - OBJECTIVE: Current guidelines recommend dual antiplatelet (AP) therapy (DAPT) before carotid artery stenting (CAS); however, the true clinical effect of single AP therapy vs DAPT is unknown. We examined the efficacy and safety of preoperative single AP therapy vs DAPT in patients who had undergone transfemoral CAS (tfCAS) or transcarotid artery revascularization (TCAR). METHODS: We identified all patients who had undergone tfCAS or TCAR in the Vascular Quality Initiative database from 2016 to 2021. We stratified the patients by procedure and identified those who had received the following preoperative AP regimens: DAPT (acetylsalicylic acid [ASA] + P2Y12 inhibitor [P2Yi]), no AP therapy, ASA only, ASA + AP loading dose, P2Yi only, and P2Yi + AP loading dose. The AP loading dose was given within 4 hours of CAS. We generated propensity scores for each treatment regimen and assessed in-hospital outcomes using inverse probability weighted log binomial regression, with DAPT as the reference and adjusting for intraoperative protamine use. The primary efficacy outcome was a composite end point of stroke and death, and the primary safety outcome was access-related bleeding. RESULTS: Of the 18,570 tfCAS patients, 70% had received DAPT, 5.6% no AP therapy, 10% ASA only, 8.0% ASA + AP loading dose, 4.6% P2Yi only, and 2.9% P2Yi + AP loading dose. The corresponding unadjusted rates of stroke/death were 2.2%, 6.8%, 4.1%, 5.1%, 2.4%, and 2.3%. After adjustment, compared with DAPT, the incidence of stroke/death was higher with no AP therapy (relative risk [RR], 2.3; 95% confidence interval [CI], 1.7-3.2), ASA only (RR, 1.6; 95% CI, 1.2-2.1), and ASA + AP loading dose (RR, 2.0; 95% CI, 1.5-2.7) but was similar with P2Yi only (RR, 0.99; 95% CI, 0.58-1.7) and P2Yi + AP loading dose (RR, 1.1; 95% CI, 0.49-2.5). Of the 25,459 TCAR patients, 81% had received DAPT, 2.0% no AP therapy, 5.5% ASA only, 3.5% ASA + AP loading dose, 4.9% P2Yi only, and 2.4% P2Yi + AP loading dose. The corresponding unadjusted rates of stroke/death were 1.5%, 3.3%, 3.3%, 2.9%, 1.2%, and 1.1%. After adjustment, compared with DAPT, the incidence of stroke/death was higher with no AP therapy (RR, 2.0; 95% CI, 1.2-3.3) and ASA only (RR, 2.2; 95% CI, 1.5-3.1), with a trend toward a higher incidence with ASA + AP loading dose (RR, 1.6; 95% CI, 0.99-2.6), and was similar with P2Yi only (RR, 0.98; 95% CI, 0.54-1.8) and P2Yi + AP loading dose (RR, 0.66; 95% CI, 0.27-1.6). No differences were found in the incidence of access-related bleeding between the treatment groups after tfCAS or TCAR. CONCLUSIONS: Compared with DAPT, no AP therapy or ASA monotherapy was associated with higher rates of stroke/death after CAS and should be discouraged as unsafe practice. Meanwhile, P2Yi monotherapy was associated with similar rates of stroke/death. No differences were found in the incidence of bleeding complications, and adding an AP loading dose to ASA or P2Yi monotherapy within 4 hours of the procedure did not affect the outcomes. Overall, these findings support the current guidelines recommending DAPT before CAS but also suggest that P2Yi monotherapy might confer thromboembolic benefits similar to those with DAPT. However, an immediate preoperative AP loading dose might not provide additional thromboembolic benefits. CI - Copyright (c) 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved. FAU - Marcaccio, Christina L AU - Marcaccio CL AD - Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. FAU - Patel, Priya B AU - Patel PB AD - Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. FAU - Rastogi, Vinamr AU - Rastogi V AD - Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands. FAU - Stangenberg, Lars AU - Stangenberg L AD - Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. FAU - Liang, Patric AU - Liang P AD - Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. FAU - Wyers, Mark C AU - Wyers MC AD - Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. FAU - Jim, Jeffrey AU - Jim J AD - Section of Vascular and Endovascular Surgery, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN. FAU - Schneider, Peter A AU - Schneider PA AD - Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA. FAU - Schermerhorn, Marc L AU - Schermerhorn ML AD - Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. Electronic address: mscherm@bidmc.harvard.edu. LA - eng GR - F32 HS027285/HS/AHRQ HHS/United States GR - T32 HL007734/HL/NHLBI NIH HHS/United States GR - UL1 TR002541/TR/NCATS NIH HHS/United States PT - Journal Article PT - Research Support, N.I.H., Extramural PT - Research Support, Non-U.S. Gov't PT - Research Support, U.S. Gov't, P.H.S. DEP - 20221226 PL - United States TA - J Vasc Surg JT - Journal of vascular surgery JID - 8407742 RN - 0 (Platelet Aggregation Inhibitors) RN - R16CO5Y76E (Aspirin) SB - IM MH - Humans MH - Platelet Aggregation Inhibitors/adverse effects MH - *Carotid Stenosis/diagnostic imaging/surgery MH - Stents/adverse effects MH - Risk Factors MH - *Stroke/epidemiology/etiology MH - Hemorrhage/chemically induced MH - *Thromboembolism MH - Aspirin/adverse effects MH - Carotid Arteries MH - Treatment Outcome MH - Retrospective Studies PMC - PMC10122699 MID - NIHMS1870490 OTO - NOTNLM OT - Carotid artery stenting OT - DAPT OT - Dual antiplatelet therapy OT - Single antiplatelet therapy OT - TCAR OT - tfCAS COIS- CONFLICTS OF INTEREST: JJ is a consultant for Silk Road Medical, Medtronic, and Endospan. PAS is a consultant for Silk Road Medical, Boston Scientific, Medtronic, Philips, Surmodics, and Cagent. EDAT- 2022/12/30 06:00 MHDA- 2023/04/25 10:19 PMCR- 2024/05/01 CRDT- 2022/12/29 19:12 PHST- 2022/07/17 00:00 [received] PHST- 2022/12/12 00:00 [revised] PHST- 2022/12/14 00:00 [accepted] PHST- 2023/04/25 10:19 [medline] PHST- 2022/12/30 06:00 [pubmed] PHST- 2022/12/29 19:12 [entrez] PHST- 2024/05/01 00:00 [pmc-release] AID - S0741-5214(22)02713-6 [pii] AID - 10.1016/j.jvs.2022.12.034 [doi] PST - ppublish SO - J Vasc Surg. 2023 May;77(5):1434-1446.e11. doi: 10.1016/j.jvs.2022.12.034. Epub 2022 Dec 26.