Optimizing TCAR Antithrombotic Regimens for Patients on Chronic Anticoagulation.

Area of Science:

• Vascular Surgery
• Cardiology
• Neurology

Background:

• Transcarotid artery revascularization (TCAR) typically uses dual antiplatelet therapy (DAPT).
• Many patients undergoing TCAR have comorbidities requiring anticoagulation.
• Evaluating alternative antithrombotic strategies is crucial for TCAR safety and efficacy.

Purpose of the Study:

• To compare the safety and efficacy of different antithrombotic regimens in TCAR patients.
• To identify optimal antithrombotic strategies for TCAR, especially in patients requiring anticoagulation.
• To analyze risks of mortality, neurologic events, and bleeding across various regimens.

Main Methods:

• Retrospective cohort study of 75,444 TCAR patients from the VQI TCAR Surveillance Project (2016-2024).
• Comparison of four groups: DAPT, single antiplatelet plus anticoagulation (SAPT+AC), triple therapy (TT), and anticoagulation alone (AC).
• Multivariate logistic regression analysis to control for confounders, assessing 30-day mortality, neurologic events, and bleeding.

Main Results:

• Dual antiplatelet therapy (DAPT) showed the best outcomes: lowest 30-day mortality (0.34%) and neurologic events (1.30%).
• Anticoagulation alone (AC) had the highest risk of neurologic events (AOR 2.15) and death/stroke (AOR 2.58).
• Triple therapy (TT) had outcomes comparable to DAPT, but with increased bleeding risk (2.5%). SAPT+AC showed higher risks than DAPT.

Conclusions:

• Dual antiplatelet therapy (DAPT) remains the preferred regimen for TCAR.
• For patients needing anticoagulation, triple therapy (TT) is a viable alternative to SAPT+AC, despite increased bleeding risk.
• In SAPT+AC regimens, P2Y12 inhibitors may offer a lower risk of intracranial bleeding compared to aspirin.