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A Murine Model of Stent Implantation in the Carotid Artery for the Study of Restenosis
Published on: May 14, 2013
Antithrombotic Therapy in Carotid Artery and Intracranial Artery Stent
Ichiro Nakagawa1, Masashi Kotsugi1, Shohei Yokoyama1
1Department of Neurosurgery, Nara Medical University, Kashihara, Nara, Japan.
Insights
Dual antiplatelet therapy (DAPT) is crucial for patients undergoing carotid artery stenting (CAS) and intracranial artery stenting (ICS). Managing antiplatelet therapy requires balancing stroke prevention with bleeding risks, especially with clopidogrel resistance.
Area of Science:
- Neurology
- Cardiology
- Vascular Surgery
Background:
- Optimal platelet inhibition is critical for patients with carotid and intracranial artery stenosis undergoing stenting procedures.
- Dual antiplatelet therapy (DAPT) is commonly used but faces challenges like clopidogrel resistance in certain populations.
- Alternative antiplatelet agents and strategies are being investigated to improve outcomes.
Purpose of the Study:
- To review the current evidence and controversies surrounding antiplatelet therapy in carotid artery stenting (CAS) and intracranial artery stenting (ICS).
- To discuss optimal antithrombotic management strategies, including DAPT duration and alternatives, for patients undergoing CAS and ICS.
- To highlight the importance of balancing efficacy and safety in perioperative antithrombotic management.
Main Methods:
- Review of existing literature on DAPT, antiplatelet resistance, and antithrombotic management in CAS and ICS.
- Analysis of studies investigating alternative antiplatelet agents and their efficacy and safety profiles.
- Discussion of current guidelines and controversies regarding DAPT duration and management in specific patient populations.
Main Results:
- DAPT is effective in reducing neurological events post-CAS but carries bleeding risks, with optimal duration remaining debated.
- Clopidogrel resistance affects approximately 20% of Asian populations, necessitating alternative strategies like adjunctive cilostazol or other agents.
- Emerging therapies like direct oral anticoagulants and glycoprotein IIb/IIIa inhibitors show promise but require further investigation and approval.
Conclusions:
- DAPT is essential for perioperative management of CAS and ICS, but specific protocols need refinement.
- Balancing the benefits of antithrombotic agents against bleeding risks is crucial for personalized patient care.
- Further research is needed to establish optimal antithrombotic strategies for diverse patient groups and procedural contexts.
Abstract:
Optimal platelet inhibition is critical in patients with carotid and intracranial artery stenosis undergoing carotid artery stenting (CAS) and intracranial artery stenting (ICS). Many reports have highlighted the importance of dual antiplatelet therapy (DAPT) in reducing adverse neurological outcomes without a significant increase in bleeding complications during CAS. DAPT has commonly used CAS and ICS, typically with aspirin and clopidogrel, but clopidogrel resistance occurs in approximately 20% of Japanese and other Asian populations. One solution to clopidogrel resistance is using adjunctive cilostazol to suppress the frequency of stroke events and in-stent restenosis after CAS. Other antiplatelet agents such as prasugrel, ticagrelor, cangrelor, and glycoprotein (GP) IIb/IIIa inhibitors are under investigation. The duration of DAPT after CAS remains controversial, as a longer duration of DAPT after CAS is associated with lower rates of readmission for stroke, but increased risk of hemorrhagic complications. Regarding antithrombotic therapy in CAS with concomitant atrial fibrillation, the use of direct oral anticoagulants plus a P2Y12 inhibitor may be suggested for the optimal safety and efficacy of antithrombotic management. For emergent CAS in acute ischemic stroke (AIS), intraprocedural DAPT loading and GP IIb/IIIa inhibitors, as necessary, may improve stent patency without increasing the risk of intracranial hemorrhage. In ICS, aggressive antiplatelet therapy based on an assessment of platelet aggregation is also important to improve clinical outcomes. In addition, rescue stenting for AIS caused by intracranial atherosclerotic stenosis-related large vessel occlusion is gaining attention. GP IIb/IIIa inhibitors have shown promise, but are not approved in Japan. In conclusion, DAPT is essential for the perioperative management of CAS and ICS. Specific perioperative antithrombotic management remains unclear, but the potential benefits of antithrombotic agents must be weighed against the corresponding increased risk of bleeding complications.
