Impact of pre-stenting antiplatelet therapy regimens on clinical outcomes following carotid artery stenting: a retrospective analysis

Year 2025, Volume: 11 Issue: 2, 135 - 142

Oguz Arslanturk , Mehmet Selim Gel , Emrah Keskin

https://doi.org/10.18621/eurj.1604476

Abstract

Objective: This study investigates the influence of various antiplatelet regimens before carotid artery stenting (CAS) on short-term and long-term clinical outcomes. Effective antiplatelet therapy is vital for enhancing the success and safety of CAS. Determining the best approach remains a priority.

Methods: This retrospective cohort analysis involved 235 patients who underwent CAS at a single institution between October 2020 and October 2024. Participants were divided into three groups based on the antiplatelet regimen administered before the procedure: dual antiplatelet therapy (DAPT), aspirin monotherapy (SAPT-A), and clopidogrel monotherapy (SAPT-C). The main outcomes evaluated were stroke, transient ischemic attack (TIA), and bleeding complications. Secondary outcomes included restenosis, stent thrombosis, and death. Statistical methods were applied to compare outcomes across the groups.

Results: Stroke (0.8%) and TIA (2.5%) were notably less frequent in the DAPT group compared to the SAPT-A (7.1% and 12.5%, respectively) and SAPT-C (6.9% and 8.6%, respectively) groups (P<0.05). Rates of stent thrombosis (1.7%-1.8%) and mortality (0.8%-3.4%) at six months showed no significant differences among the groups (P>0.05).

Conclusions: Pre-procedural DAPT reduces short-term ischemic complications in CAS. However, long-term outcomes were comparable across regimens. These findings suggest that antiplatelet strategies should be individualized. Larger studies with longer follow-ups are needed.

Keywords

Carotid artery stenting, dual antiplatelet therapy, aspirin, clopidogrel, ischemic complications, restenosis, transient ischemic attack

Ethical Statement

This study was conducted in accordance with the ethical principles outlined in the 2008 Declaration of Helsinki. Ethical approval was obtained from the Zonguldak Bülent Ecevit University Clinical Research Ethics Committee (Approval No: 2024/22-1). All patient data were anonymized to ensure confidentiality and privacy.

References

• 1. Wabnitz AM, Turan TN. Symptomatic Carotid Artery Stenosis: Surgery, Stenting, or Medical Therapy? Curr Treat Options Cardiovasc Med. 2017;19(8):62. doi: 10.1007/s11936-017-0564-0.
• 2. Nicolaides AN, Kakkos SK, Griffin M, et al. Severity of asymptomatic carotid stenosis and risk of ipsilateral hemispheric ischaemic events: results from the ACSRS study. Eur J Vasc Endovasc Surg. 2005;30(3):275-284. doi: 10.1016/j.ejvs.2005.04.031.
• 3. Aichner FT, Topakian R, Alberts MJ, et al. High cardiovascular event rates in patients with asymptomatic carotid stenosis: the REACH Registry. Eur J Neurol. 2009;16(8):902-908. doi: 10.1111/j.1468-1331.2009.02614.x.
• 4. Inzitari D, Eliasziw M, Gates P, et al. The causes and risk of stroke in patients with asymptomatic internal-carotid-artery stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med. 2000;342(23):1693-1700. doi: 10.1056/NEJM200006083422302.
• 5. Marquardt L, Geraghty OC, Mehta Z, Rothwell PM. Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treatment: a prospective, population-based study. Stroke. 2010;41(1):e11-17. doi: 10.1161/STROKEAHA.109.561837.
• 6. Kerber CW, Cromwell LD, Loehden OL. Catheter dilatation of proximal carotid stenosis during distal bifurcation endarterectomy. AJNR Am J Neuroradiol. 1980;1(4):348-349.
• 7. Theron JG, Payelle GG, Coskun O, Huet HF, Guimaraens L. Carotid artery stenosis: treatment with protected balloon angioplasty and stent placement. Radiology. 1996;201(3):627-636. doi: 10.1148/radiology.201.3.8939208.
• 8. Helgason CM, Bolin KM, Hoff JA, et al. Development of aspirin resistance in persons with previous ischemic stroke. Stroke. 1994;25(12):2331-2336. doi: 10.1161/01.str.25.12.2331.
• 9. Urban P, Macaya C, Rupprecht HJ, et al. Randomized evaluation of anticoagulation versus antiplatelet therapy after coronary stent implantation in high-risk patients: the multicenter aspirin and ticlopidine trial after intracoronary stenting (MATTIS). Circulation. 1998;98(20):2126-2132. doi: 10.1161/01.cir.98.20.2126.
• 10. McKevitt FM, Randall MS, Cleveland TJ, Gaines PA, Tan KT, Venables GS. The benefits of combined anti-platelet treatment in carotid artery stenting. Eur J Vasc Endovasc Surg. 2005;29(5):522-527. doi: 10.1016/j.ejvs.2005.01.012.
• 11. Bhatt DL, Kapadia SR, Bajzer CT, et al. Dual antiplatelet therapy with clopidogrel and aspirin after carotid artery stenting. J Invasive Cardiol. 2001;13(12):767-771.
• 12. Markus HS, Droste DW, Kaps M, et al. Dual antiplatelet therapy with clopidogrel and aspirin in symptomatic carotid stenosis evaluated using doppler embolic signal detection: the Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic Carotid Stenosis (CARESS) trial. Circulation. 2005;111(17):2233-2240. doi: 10.1161/01.CIR.0000163561.90680.1C.
• 13. Leon MB, Baim DS, Popma JJ, et al. A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators. N Engl J Med. 1998;339(23):1665-1671.
• 14. Iakovou I, Schmidt T, Bonizzoni E, et al. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA. 2005;293(17):2126-2130. doi: 10.1001/jama.293.17.2126.
• 15. Chaturvedi S, Yadav JS. The role of antiplatelet therapy in carotid stenting for ischemic stroke prevention. Stroke. 2006;37(6):1572-1577. doi: 10.1161/01.STR.0000221298.43117.be.
• 16. Frostegard J. Immunity, atherosclerosis and cardiovascular disease. BMC Med. 2013;11:117. doi: 10.1186/1741-7015-11-117.
• 17. Cremonesi A, Castriota F, Secco GG, Macdonald S, Roffi M. Carotid artery stenting: an update. Eur Heart J. 2015;36(1):13-21. doi: 10.1093/eurheartj/ehu446.
• 18. Pini R, Faggioli G, Paraskevas KI, et al. Carotid Artery Stenting with Double-Layer Stent: A Systematic Review and Meta-Analysis. J Endovasc Ther. 2024;31(3):339-349. doi:10.1177/15266028221126940.
• 19. Yoo J, Lim H, Seo KD. Optimal Duration of Dual Antiplatelet Therapy After Carotid Artery Stenting: A Nationwide Cohort Study. Stroke. 2025 Jan 17. doi:10.1161/STROKEAHA.124.048743. Epub ahead of print.
• 20. Diener HC, Bogousslavsky J, Brass LM, et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet. 2004;364(9431):331-337. doi: 10.1016/S0140-6736(04)16721-4.
• 21. Diener HC, Bogousslavsky J, Brass LM, et al. Management of atherothrombosis with clopidogrel in high-risk patients with recent transient ischaemic attack or ischaemic stroke (MATCH): study design and baseline data. Cerebrovasc Dis. 2004;17(2-3):253-261. doi: 10.1159/000076962.
• 22. Ferguson GG, Eliasziw M, Barr HW, et al. The North American Symptomatic Carotid Endarterectomy Trial: surgical results in 1415 patients. Stroke. 1999;30(9):1751-1758. doi: 10.1161/01.str.30.9.1751.
• 23. Brott TG, Hobson RW 2nd, Howard G, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363(1):11-23. doi: 10.1056/NEJMoa0912321.