Related Experiment Video
Updated: Jun 30, 2026
A Murine Model of Stent Implantation in the Carotid Artery for the Study of Restenosis
Published on: May 14, 2013
In-Stent Stenosis or Occlusion After Carotid Artery Stenting in Patients Treated With Anticoagulants vs Antiplatelet
Mert Kök1, Reinoud P H Bokkers2, Aryan Mazuri2
1Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, The Netherlands.
Insights
Patients on anticoagulants after carotid artery stenting (CAS) may face higher mid-term in-stent stenosis risks, particularly those using direct oral anticoagulants (DOACs). Further research is needed to confirm findings and guide antithrombotic therapy post-CAS.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Neurology
Background:
- Increasing use of anticoagulants in patients undergoing carotid artery stenting (CAS) complicates standard dual antiplatelet therapy.
- Alternative antithrombotic strategies, often involving single antiplatelet agents, are used to mitigate bleeding risks in anticoagulated patients.
- Concerns exist that these modified regimens may increase the risk of in-stent stenosis and subsequent ischemic events.
Purpose of the Study:
- To investigate the association between anticoagulant use and the incidence of in-stent stenosis following CAS.
- To compare mid-term in-stent stenosis rates between patients treated with anticoagulants versus antiplatelets after CAS.
- To evaluate the impact of different antithrombotic strategies on secondary outcomes, including thromboembolic and bleeding complications.
Main Methods:
- Retrospective cohort study including 327 patients who underwent CAS for significant carotid artery stenosis.
- Patients were categorized into anticoagulant or antiplatelet groups based on post-procedural antithrombotic management.
- Primary outcome was in-stent stenosis assessed at short-term and mid-term follow-ups; sensitivity analysis used multiple imputation for missing data.
Main Results:
- Mid-term in-stent stenosis rates were significantly higher in the anticoagulant group (21.6%) compared to the antiplatelet group (7.4%) in the primary analysis (P=.01).
- Symptomatic in-stent stenosis was also more frequent in the anticoagulant group (10.5% vs 1.0%, P=.01), primarily among direct oral anticoagulant (DOAC) users.
- Sensitivity analysis revealed a non-significant association between anticoagulant use and mid-term in-stent stenosis (OR 1.29, P=.56), and no significant differences in secondary outcomes were observed.
Conclusions:
- The primary analysis suggests a potential association between anticoagulant use, particularly DOACs, and increased mid-term symptomatic in-stent stenosis after CAS.
- This association was not consistently supported by the sensitivity analysis, highlighting the need for cautious interpretation.
- Prospective studies are essential to definitively guide antithrombotic therapy choices for anticoagulated patients undergoing CAS.
Introduction:
Rise in anticoagulant use increases the likelihood that patients undergoing carotid artery stenting (CAS) are on anticoagulants. This complicates postprocedural antithrombotic management, as dual antiplatelet therapy is standard to reduce stent-related complications. To mitigate bleeding risks, patients on anticoagulants often briefly receive a single antiplatelet agent instead. Based on clinical practice, we hypothesized this regimen may increase in-stent stenosis, potentially raising the risk of recurrent ipsilateral transient ischemic attack or ischemic stroke.
Design:
Single-center, retrospective cohort study at a tertiary referral center.
Methods:
Patients with significant carotid artery stenosis treated with CAS (May 2005 to September 2024) were categorized into the anticoagulant (with or without antiplatelet therapy) or antiplatelet group (mono therapy or dual therapy). Primary outcome was in-stent stenosis at short-term (30 days to 8 weeks) and mid-term (1 year) follow-ups. Secondary outcomes included 30-day composite of thromboembolic and bleeding complications, reintervention, and other procedure-related adverse events. For the sensitivity analysis, multiple imputation was performed to address missing data.
Results:
Among 327 patients, 274 (83.8%) received antiplatelets and 53 (16.2%) anticoagulants. In-stent stenosis rates did not differ at short term (2.1% vs 2.8%, P = 1.00) but were higher in the anticoagulant group at mid-term (21.6% vs 7.4%, P = .01; adjusted odds ratio [OR] 3.29, 95% confidence interval [CI] 1.16-9.39), with more symptomatic cases (10.5% vs 1.0%, P = .01). All occurred in direct oral anticoagulant (DOAC) users, 75% also on single antiplatelet therapy. However, sensitivity analysis yielded a non-significant association (OR 1.29, 95% CI 0.54-3.07, P = .56). Secondary outcomes showed no significant differences.
Conclusion:
Anticoagulant use, specifically DOACs, appears associated with increased mid-term (symptomatic) in-stent stenosis in the primary analysis. However, this association was attenuated in the sensitivity analysis. Prospective studies are warranted to guide post-CAS antithrombotic therapy in anticoagulated patients.Clinical ImpactAs the number of patients undergoing carotid artery stenting while receiving oral anticoagulation continues to rise, clinicians face uncertainty regarding optimal post-procedural antithrombotic therapy. This study identifies a potential association between anticoagulant use, particularly direct oral anticoagulants, and increased mid-term carotid in-stent stenosis. Confirmation in prospective studies is required. The innovation of this study lies in addressing an important evidence gap in carotid intervention practice, providing the first comparison of in-stent stenosis outcomes between anticoagulant- and antiplatelet-treated patients.
Related Concept Videos
01:20Antiplatelet Drugs: Prostaglandin Synthesis, P2Y12 and Glycoprotein IIb/IIIa Inhibitors
Prostaglandin synthesis inhibitors, exemplified by the widely known aspirin, wield their power by irreversibly acetylating...
01:27Coronary Artery Disease V: Interprofessional Care
01:27Peripheral Artery Disease III: Interprofessional Care
01:26Angina IV: Management
01:27Angina II: Classification
01:26Atherosclerosis III: Management