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Updated: Aug 11, 2025
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Comparison of three antithrombotic strategies for emergent carotid stenting during stroke thrombectomy: a multicenter
Raoul Pop1,2,3, Julien Burel4, Stephanos Nikolaos Finitsis5
1Interventional Neuroradiology, University Hospitals Strasbourg, Strasbourg, France pop.raoul@gmail.com.
Insights
Aggressive antiplatelet therapy improved recanalization and reduced stent thrombosis in emergent carotid artery stenting (eCAS) during stroke thrombectomy. This strategy showed no increased safety concerns, offering valuable insights for treatment choices.
Area of Science:
- Neurology
- Interventional Cardiology
- Vascular Surgery
Background:
- Periprocedural antithrombotic treatment is critical for the risk-benefit balance of emergent carotid artery stenting (eCAS) during stroke thrombectomy.
- Assessing safety and efficacy of different antithrombotic strategies is crucial for optimizing patient outcomes.
Purpose of the Study:
- To evaluate the safety and efficacy of three distinct periprocedural antithrombotic treatment protocols for emergent carotid artery stenting (eCAS) in stroke patients.
- To compare outcomes between aggressive antiplatelet strategies and non-aggressive approaches (aspirin ± heparin).
Main Methods:
- Retrospective analysis of prospectively collected endovascular databases from four comprehensive stroke centers (January 2019 - July 2021).
- Inclusion of consecutive cases of eCAS for tandem lesion strokes.
- Categorization of patients into three treatment groups: aspirin monotherapy, aspirin plus heparin, and aggressive antiplatelet therapy (aspirin, clopidogrel, with optional tirofiban).
Main Results:
- Aggressive antiplatelet treatment was linked to higher rates of excellent recanalization (modified Thrombolysis in Cerebral Infarction (mTICI) 2c-3) and reduced carotid stent thrombosis at day 1 (3.5% vs. 16.3%) compared to non-aggressive strategies.
- No significant differences were observed in hemorrhagic transformation or 90-day mortality across the groups.
- Addition of heparin to aspirin did not improve carotid stent patency rates.
Conclusions:
- Aggressive antiplatelet treatment demonstrates improved intracranial recanalization and carotid stent patency without compromising safety in eCAS.
- Findings support the potential utility of aggressive antiplatelet strategies in clinical practice and for informing future randomized trials.
Background:
Periprocedural antithrombotic treatment is a key determinant for the risk-benefit balance of emergent carotid artery stenting (eCAS) during stroke thrombectomy. We aimed to assess the safety and efficacy of three types of antithrombotic treatment.
Methods:
Retrospective review of prospectively collected endovascular databases in four comprehensive stroke centers, including consecutive cases of eCAS for tandem lesion strokes between January 2019 and July 2021. During this period, each center prospectively applied one of three periprocedural protocols: (a) two centers administered aspirin (250 mg IV); (b) one center administered aspirin and heparin (bolus+24 hours infusion); and (c) one center applied an aggressive antiplatelet strategy consisting of aspirin and clopidogrel (loading doses), with added intravenous tirofiban if in-stent thrombosis was observed during thrombectomy. Dichotomized comparisons of outcomes were performed between aggressive versus non-aggressive strategy (aspirin±heparin) and aspirin+heparin versus aspirin-alone groups.
Results:
Among 161 included patients, 62 received aspirin monotherapy, 38 aspirin+heparin, and 61 an aggressive treatment. Aggressive antiplatelet treatment was associated with an increased rate of excellent (modified Thrombolysis in Cerebral Infarction (mTICI) 2c-3) recanalization and reduced carotid stent thrombosis at day 1 (3.5% vs 16.3%), compared with non-aggressive strategy. There were no significant differences in hemorrhagic transformation or 90-day mortality. There was a tendency towards better clinical outcome with aggressive treatment, without reaching statistical significance. Addition of heparin to aspirin was not associated with an increased rate of carotid stent patency.
Conclusions:
Aggressive antiplatelet treatment was associated with improved intracranial recanalization and carotid stent patency, without safety concerns. These findings have implications for randomized trials and may be of utility for clinicians when making antithrombotic treatment choices.
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