Background
Despite many patients undergoing carotid endarterectomy (CEA) being on dual antiplatelet
therapy (DAPT) for cardiac or neurologic indications, the impact of such therapy on
perioperative outcomes remains unclear. We aim to compare rates of postoperative bleeding,
stroke and major adverse events (stroke, death or MI) among patients on Aspirin alone
(ASAA) versus DAPT (Clopidogrel and Aspirin).
Methods
Patients undergoing CEA for carotid artery stenosis between 2010 and 2021 in the Vascular
Quality Initiative (VQI) were included. We excluded patients undergoing concomitant
or re-do operations or patients with missing antiplatelet information. Propensity
score matching was performed between the 2 groups ASAA and DAPT based on age, sex,
race, presenting symptoms, major comorbidities [hypertension, diabetes and coronary
artery disease (CAD)], degree of ipsilateral stenosis, presence of contralateral occlusion,
as well as preoperative medications. Intergroup differences between the treatment
groups and differences in perioperative outcomes were tested with the McNemar's test
for categorical variables and paired t-test or Wilcoxon matched-pairs signed-rank test for continuous variables where appropriate.
Relative risks with 95% confidence intervals were estimated as the ratio of the probability
of the outcome event in the patients treated within each treatment group.
Results
A total of 125,469 patients were included [ASAA n = 82,920 (66%) and DAPT n = 42,549 (34%)]. Patients on DAPT were more likely to be symptomatic, had higher
rates of CAD, prior percutaneous coronary intervention or coronary artery bypass grafting,
and higher rates of diabetes. After propensity score matching, the DAPT group had
an increased rate of bleeding complications (RR: 1.6: 1.4–1.8, P < 0.001) as compared with those on ASAA despite being more likely to receive both
drains and protamine. In addition, patients on DAPT had a slight decrease in the risk
of in-hospital stroke as compared with patients on ASAA (RR: 0.80: 0.7–0.9, P = 0.001).
Conclusions
This large multi-institutional study demonstrates a modest decrease in the risk of
in-hospital stroke for patients on DAPT undergoing CEA as compared with those on ASAA.
This small benefit is at the expense of a significant increase in the risk of perioperative
bleeding events incurred by those on DAPT at the time of CEA. This analysis suggests
avoiding DAPT when possible, during CEA.
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Article Info
Publication History
Published online: July 31, 2022
Accepted:
July 7,
2022
Received:
April 15,
2022
Publication stage
In Press Journal Pre-ProofFootnotes
Disclosures: None declared.
Rohini J Patel: National Library of Medicine , T15 Postdoctoral Training Grant Fellowship Program in Biomedical Informatics, NIH grant T15LM011271 .
Identification
Copyright
© 2022 Elsevier Inc. All rights reserved.
