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Optimizing TCAR Antithrombotic Regimens for Patients on Chronic Anticoagulation
Ali Hakimi1, Tarik Ali1, Shreya Rawat2
1Division of Vascular Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA.
Insights
Dual antiplatelet therapy (DAPT) is optimal for transcarotid artery revascularization (TCAR). For patients needing anticoagulation, triple therapy is better than single antiplatelet plus anticoagulation, but carries higher bleeding risk.
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.
Background:
While dual antiplatelet therapy (DAPT) remains the standard for transcarotid artery revascularization (TCAR), many patients require anticoagulation for medical comorbidities. We evaluated the safety and efficacy of different antithrombotic regimens in TCAR patients.
Methods:
This retrospective cohort study used the Society for Vascular Surgery Vascular Quality Initiative TCAR Surveillance Project database (2016-2024). Among 75,444 patients, we compared four groups: dual antiplatelet therapy (DAPT, n = 62,847, 83.3%), single antiplatelet plus anticoagulation (SAPT + AC, n = 5,102, 6.8%), triple therapy (TT, n = 6,104, 8.1%), and anticoagulation alone (AC, n = 1,391, 1.8%). Primary outcomes included 30-day mortality, neurologic events, and composite death/stroke. Multivariate logistic regression controlled for confounders. Secondary outcomes included perioperative bleeding, myocardial infarction, and dysrhythmia.
Results:
Overall 30-day mortality was 0.4%, and the incidence of neurologic events was 1.39%. DAPT demonstrated superior outcomes with lowest 30-day mortality (0.34%), neurologic events (1.30%), and composite death/stroke (1.59%). After adjustment, SAPT + AC had significantly higher odds of neurologic events (AOR 1.52, P = 0.001) and composite death/stroke (AOR 1.58, P < 0.001) versus DAPT. AC alone showed the highest risk for neurologic events (AOR 2.15, P < 0.001) and composite death/stroke (AOR 2.58, P < 0.001). TT outcomes were comparable outcomes to DAPT. Perioperative bleeding rates (access site, retroperitoneal, or intracranial) increased progressively: DAPT (1.6%), SAPT + AC (2.0%), TT (2.5%), and AC alone (2.7%). Within SAPT + AC, P2Y12 inhibitors had lower intracranial bleeding than aspirin (0.37% vs. 1.12%, P = 0.005).
Conclusion:
DAPT remains optimal for TCAR. For patients requiring AC, TT appears preferable to SAPT + AC and, however, does have an increased bleeding risk. When SAPT + AC is necessary, P2Y12 inhibitors may have decreased risk of bleeding versus aspirin.
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