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Published on: August 12, 2014
Preoperative antithrombotic treatment in acutely symptomatic carotid artery stenosis
Juan Carlos Martinez-Gutierrez1, Alexis T Roy2, Salvatore D'Amato1
1Department of Neurosurgery, UTHealth McGovern Medical School, 6400 Fannin ST, Houston, TX 77030, United States; Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States.
Insights
Short-term anticoagulation before carotid endarterectomy (CEA) significantly reduced recurrent stroke or TIA compared to antiplatelet agents alone. This anticoagulant approach appears safe for patients with symptomatic carotid stenosis awaiting surgery.
Area of Science:
- Vascular Neurology
- Neurosurgery
- Cardiology
Background:
- Acutely symptomatic carotid artery stenosis poses a high risk for early recurrent cerebral ischemia before revascularization.
- The optimal antithrombotic strategy for this patient group remains unclear, with limited evidence supporting anticoagulants over antiplatelet agents.
Purpose of the Study:
- To evaluate the safety and efficacy of short-term preoperative anticoagulation for secondary prevention of recurrent ischemic events in patients with symptomatic carotid stenosis awaiting carotid endarterectomy (CEA).
Main Methods:
- A retrospective analysis of a prospective registry compared patients receiving anticoagulation (AC) versus antiplatelet (AP) therapy.
- The study included patients with acute ischemic stroke or TIA attributed to internal carotid artery stenosis undergoing CEA.
- Primary outcomes included preoperative recurrent stroke/TIA and symptomatic intracranial hemorrhage.
Main Results:
- The anticoagulation group (342 patients) showed a significantly lower incidence of recurrent stroke/TIA (3.8%) compared to the antiplatelet group (101 patients, 10.9%).
- Symptomatic intracranial hemorrhage occurred in one patient in the AC group and none in the AP group.
- Multivariate analysis confirmed anticoagulation as protective against recurrent events (OR 0.30, p=0.007), even in patients without intraluminal thrombus.
Conclusions:
- Short-term preoperative anticoagulation is a safe and effective alternative to antiplatelet agents alone for preventing recurrent cerebral ischemia in patients with acutely symptomatic carotid stenosis awaiting CEA.
Objectives:
Early recurrence of cerebral ischemia in acutely symptomatic carotid artery stenosis can precede revascularization. The optimal antithrombotic regimen for this high-risk population is not well established. Although antiplatelet agents are commonly used, there is limited evidence for the use of anticoagulants. We sought to understand the safety and efficacy of short-term preoperative anticoagulants in secondary prevention of recurrent cerebral ischemic events from acutely symptomatic carotid stenosis in patients awaiting carotid endarterectomy (CEA).
Materials And Methods:
A retrospective query of a prospective single institution registry of carotid revascularization was performed. Patients who presented with acute ischemic stroke or transient ischemic attack (TIA) attributable to an ipsilateral internal carotid artery stenosis (ICA) were included. Antiplatelet (AP) only and anticoagulation (AC) treatment arms were compared. The primary outcome was a composite of preoperative recurrent ischemic stroke or TIA. The primary safety outcome was symptomatic intracranial hemorrhage.
Results:
Out of 443 CEA patients, 342 were in the AC group and 101 in the AP group. Baseline characteristics between groups (AC vs AP) were similar apart from age (71±10.5 vs 73±9.5, p=0.04), premorbid modified Rankin scale (mRS) score (1.0±1.2 vs 1.4±1.3, p=0.03) and stroke as presenting symptom (65.8 vs 53.5%, p=0.02). Patients in the AC group had a lower incidence of recurrent stroke/TIA (3.8 vs 10.9%, p=0.006). One patient had symptomatic intracranial hemorrhage in the AC group, and none in the AP group. In multivariate analysis controlling for age, premorbid mRS, stroke severity, degree of stenosis, presence of intraluminal thrombus (ILT) and time to surgery, AC was protective (OR 0.30, p=0.007). This effect persisted in the cohort exclusively without ILT (OR 0.23, p=0.002).
Conclusions:
Short term preoperative anticoagulation in patients with acutely symptomatic carotid stenosis appears safe and effective compared to antiplatelet agents alone in the prevention of recurrent cerebral ischemic events while awaiting CEA.
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