Optimal periprocedural antithrombotic treatment in carotid interventions: An international, multispecialty, expert review and position statement

Kosmas I Paraskevas¹, Peter Gloviczki², Dimitri P Mikhailidis³, Pier Luigi Antignani⁴, Alan Dardik⁵, Hans-Henning Eckstein⁶, Gianluca Faggioli⁷, Jose Fernandes E Fernandes⁸, Gustav Fraedrich⁹, Ajay Gupta¹⁰, Arkadiusz Jawien¹¹, Mateja K Jezovnik¹², Stavros K Kakkos¹³, Michael Knoflach¹⁴, Brajesh K Lal¹⁵, Gaetano Lanza¹⁶, Christos D Liapis¹⁷, Ian M Loftus¹⁸, Armando Mansilha¹⁹, Antoine Millon²⁰, Rodolfo Pini⁷, Pavel Poredos²¹, Robert M Proczka²², Jean-Baptiste Ricco²³, Tatjana Rundek²⁴, Luca Saba²⁵, Felix Schlachetzki²⁶, Mauro Silvestrini²⁷, Francesco Spinelli²⁸, Francesco Stilo²⁸, Jasjit S Suri²⁹, Clark J Zeebregts³⁰, Carl J Lavie³¹, Seemant Chaturvedi³²

Affiliations

¹ Department of Vascular Surgery, Central Clinic of Athens, Athens, Greece. Electronic address: paraskevask@hotmail.com.
² Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA.
³ Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK.
⁴ Vascular Centre, Nuova Villa Claudia, Rome, Italy.
⁵ Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT, USA.
⁶ Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
⁷ Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy.
⁸ Department of Vascular Surgery, University of Lisbon, Lisbon Academic Medical Center, Lisbon, Portugal.
⁹ Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria.
¹⁰ Department of Radiology, Weill Cornell Medicine, New York, NY, USA.
¹¹ Department for Vascular Surgery and Angiology, L. Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland.
¹² Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA.
¹³ Department of Vascular Surgery, University of Patras Medical School, Patras, Greece.
¹⁴ Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.
¹⁵ Division of Vascular Surgery, University of Maryland, Baltimore, MD, USA.
¹⁶ Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Italy.
¹⁷ Athens Vascular Research Center, Athens, Greece.
¹⁸ St. George's Vascular Institute, St. George's University London, London, UK.
¹⁹ Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal.
²⁰ Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, France.
²¹ Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia.
²² 1(st) Department of Vascular Surgery, Medicover Hospital, Warsaw, Poland.
²³ Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France.
²⁴ Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA.
²⁵ Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy.
²⁶ Department of Neurology, University Hospital of Regensburg, Regensburg, Germany.
²⁷ Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy.
²⁸ Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy.
²⁹ Stroke Diagnostic and Monitoring Division, Atheropoint™, Roseville, CA, USA.
³⁰ Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
³¹ Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, Louisiana, LA, USA.
³² Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore, MD, USA.

PMID: 36265593
DOI: 10.1016/j.pcad.2022.10.002

Review

Optimal periprocedural antithrombotic treatment in carotid interventions: An international, multispecialty, expert review and position statement

Kosmas I Paraskevas et al. Prog Cardiovasc Dis. 2022 Sep-Oct.

. 2022 Sep-Oct:74:28-37.

doi: 10.1016/j.pcad.2022.10.002. Epub 2022 Oct 18.

Authors

Affiliations

¹ Department of Vascular Surgery, Central Clinic of Athens, Athens, Greece. Electronic address: paraskevask@hotmail.com.
² Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA.
³ Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK.
⁴ Vascular Centre, Nuova Villa Claudia, Rome, Italy.
⁵ Division of Vascular Surgery and Endovascular Therapy, Yale University School of Medicine, New Haven, CT, USA.
⁶ Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
⁷ Vascular Surgery, University of Bologna "Alma Mater Studiorum", Policlinico S. Orsola Malpighi, Bologna, Italy.
⁸ Department of Vascular Surgery, University of Lisbon, Lisbon Academic Medical Center, Lisbon, Portugal.
⁹ Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria.
¹⁰ Department of Radiology, Weill Cornell Medicine, New York, NY, USA.
¹¹ Department for Vascular Surgery and Angiology, L. Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland.
¹² Department of Advanced Cardiopulmonary Therapies and Transplantation, The University of Texas Health Science Centre at Houston, Houston, TX, USA.
¹³ Department of Vascular Surgery, University of Patras Medical School, Patras, Greece.
¹⁴ Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.
¹⁵ Division of Vascular Surgery, University of Maryland, Baltimore, MD, USA.
¹⁶ Vascular Surgery Department, IRCSS MultiMedica Hospital, Castellanza, Italy.
¹⁷ Athens Vascular Research Center, Athens, Greece.
¹⁸ St. George's Vascular Institute, St. George's University London, London, UK.
¹⁹ Faculty of Medicine of the University of Porto, Porto, Portugal; Department of Angiology and Vascular Surgery, Hospital de S. Joao, Porto, Portugal.
²⁰ Department of Vascular and Endovascular Surgery, Louis Pradel Hospital, Hospices Civils de Lyon, France.
²¹ Department of Vascular Disease, University Medical Centre Ljubljana, Slovenia.
²² 1(st) Department of Vascular Surgery, Medicover Hospital, Warsaw, Poland.
²³ Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France.
²⁴ Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA.
²⁵ Department of Radiology, Azienda Ospedaliera Universitaria Di Cagliari, Cagliari, Italy.
²⁶ Department of Neurology, University Hospital of Regensburg, Regensburg, Germany.
²⁷ Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy.
²⁸ Vascular Surgery Division, Campus Bio-Medico University of Rome, Rome, Italy.
²⁹ Stroke Diagnostic and Monitoring Division, Atheropoint™, Roseville, CA, USA.
³⁰ Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
³¹ Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, Louisiana, LA, USA.
³² Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore, MD, USA.

PMID: 36265593
DOI: 10.1016/j.pcad.2022.10.002

Abstract

Background: The optimal antithrombotic (antiplatelet or anticoagulant) treatment of patients undergoing extracranial carotid artery interventions is a subject of debate. The aim of this multidisciplinary document was to critically review the recommendations of current guidelines, taking into consideration the results of recently published studies.

Methods: The various antithrombotic strategies reported were evaluated for asymptomatic and symptomatic patients undergoing extracranial carotid artery interventions (endarterectomy, transfemoral carotid artery stenting [CAS] or transcarotid artery revascularization [TCAR]). Based on a critical review, a series of recommendations were formulated by an international expert panel.

Results: For asymptomatic patients, we recommend low-dose aspirin (75-100 mg/day) or clopidogrel (75 mg/day) with the primary goal to reduce the risk of myocardial infarction and cardiovascular event rates rather than to reduce the risk of stroke. For symptomatic patients, we recommend dual antiplatelet treatment (DAPT) initiated within 24 h of the index event to reduce the risk of recurrent events. We suggest that following transfemoral CAS or TCAR, patients continue DAPT for 1 month after which a single antiplatelet agent is used. High level of evidence to support anticoagulant treatment for patients with carotid artery disease is lacking.

Conclusions: The antithrombotic treatment offered to carotid patients should be individualized, taking into account the presence of symptoms, the type of intervention and the goal of the treatment. The duration and type of DAPT (ticagrelor instead of clopidogrel) should be evaluated in future trials.

Keywords: Antithrombotic treatment; Aspirin; Carotid artery stenting; Carotid endarterectomy; Clopidogrel; Stroke; TCAR.

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Conflict of interest statement

Declaration of Competing Interest Dr. Mikhailidis has given talks, acted as a consultant or attended conferences sponsored by Amgen and Novo Nordisk. Dr. Chaturvedi reports consulting for Astra Zeneca and BrainGate and serving as an Associate Editor for Stroke, and as an Editorial Board Member of Neurology and Journal of Stroke and Cerebrovascular Diseases. The other authors report no conflicts.

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Optimal periprocedural antithrombotic treatment in carotid interventions: An international, multispecialty, expert review and position statement

Affiliations

Optimal periprocedural antithrombotic treatment in carotid interventions: An international, multispecialty, expert review and position statement

Authors

Affiliations

Abstract

Conflict of interest statement

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LinkOut - more resources

Full Text Sources

Medical