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Anticoagulants, antiaggregants or nothing following carotid endarterectomy?
G Bischof1, T Pratschner, M Kail
1University Clinic of Surgery I, Vienna, Austria.
Insights
Anticoagulation (AC) and antiplatelet therapy (ASA) did not significantly differ in prolonging life after carotid endarterectomy (TEA). Both therapies showed improved survival compared to no medication, with no increased risk of cerebral hemorrhage.
Area of Science:
- Vascular Surgery
- Cardiovascular Medicine
- Clinical Pharmacology
Background:
- Carotid endarterectomy (TEA) is a key intervention for symptomatic patients with carotid artery stenosis.
- Anticoagulation (AC) and antiplatelet therapy (ASA) are commonly used post-vascular surgery for patients with peripheral occlusive arterial disease (PAOD).
- The comparative impact of AC and ASA on long-term survival after TEA, considering potential risks like cerebral hemorrhage, requires investigation.
Purpose of the Study:
- To evaluate whether anticoagulation (AC) or antiplatelet therapy (ASA) improves patient survival following carotid endarterectomy (TEA).
- To compare the efficacy of AC and ASA in prolonging life after TEA in patients with peripheral occlusive arterial disease (PAOD).
- To assess the incidence of cerebral hemorrhage associated with AC and ASA use post-TEA.
Main Methods:
- Retrospective analysis of 328 patients undergoing elective carotid endarterectomy between 1979-1986.
- Patient survival and causes of death were primary endpoints, with data from the Austrian Central Bureau of Statistics used for recent information.
- Kaplan-Meier estimation and Breslow/Mantel tests were used for survival analysis; a stepwise Cox regression model adjusted for prognostic factors (age, cardiac pathology, diabetes) for matched group comparisons.
Main Results:
- Median postoperative survival was 7.72 years for ASA, 8.48 years for AC, and 6.07 years for the no-medication group (p=0.0095).
- No significant difference in survival was observed between patients treated with AC and those treated with ASA.
- Causes of death were balanced across groups, with no increased incidence of intracerebral hemorrhage detected in AC or ASA groups.
Conclusions:
- Both anticoagulation (AC) and antiplatelet therapy (ASA) appear to prolong survival after carotid endarterectomy (TEA) compared to no medication.
- There is no significant difference in survival benefit between AC and ASA in patients undergoing TEA.
- Long-term AC and ASA use post-TEA do not appear to increase the risk of fatal cerebral hemorrhage.
Abstract:
Carotid endarterectomy (TEA) has proven to be beneficial for symptomatic patients. Anticoagulation (AC) and antiplatelet therapy (ASA) have been shown to prolong life following vascular surgery in patients with occlusive arterial disease (PAOD). To determine whether ASA or AC prolong life after TEA, retrospective analysis was undertaken, since cerebral haemorrhage is associated with the use of both drugs, especially AC. Between 1979-1986, 328 patients with stenotic lesions of the carotid bifurcation were operated upon electively. Patient survival and causes of death were the primary end points of the analysis. Recent data were obtained from the Austrian Central Bureau of Statistics. Cumulative survival rates were calculated by Kaplan-Meier estimation and differences determined by Breslow and Mantel tests. 36 patients were on AC, 157 on ASA and 135 remained without medication (0-group). Since the common risk factors in PAOD were unevenly distributed between groups, a stepwise Cox regression model was applied which revealed age (p < 0.01), cardiac pathology (p < 0.01) and diabetes (p < 0.05) as relevant for survival. Therefore, ASA patients and 0-group patients were selected and matched, employing the aforementioned prognostic criteria, and compared to the patients on long-term AC for various indications (vein bypass surgery, myocardial infarction, pulmonary embolism; i.e. data-matching). The median postoperative survival was 7.72 years for ASA and 8.48 years for AC, compared to 6.07 years for the 0-group (p = 0.0095 Breslow, p = 0.477 Mantel). There was no significant difference between AC and ASA treated patients. Irrespective of medication, the causes of death were well balanced, and no higher incidence of intracerebral haemorrhage was detected.(ABSTRACT TRUNCATED AT 250 WORDS)