Dual Antiplatelet Alternatives are Associated with Increased Stroke and Death after Transcarotid Revascularization.

OBJECTIVE: To define the risks associated with the replacement of dual antiplatelets for alternate medication regimens.

SUMMARY BACKGROUND DATA: Patients undergoing transcarotid artery revascularization (TCAR) for atherosclerotic disease in the Vascular Quality Initiative database from September 2016-June 2022 were included. In all, 29,802 TCAR procedures were captured between 2016-2022, consisting of 24,651 (82.7%) maintained on dual antiplatelet therapy (DAPT) and 5,151 (17.3%) on alternative regimens.

METHODS: Patients maintained on DAPT were compared to those on alternative regimens consisting of any combination of single antiplatelet monotherapy and/or anticoagulation.

RESULTS: On univariable analysis, patients on alternative medications were more likely to experience in-hospital death, ipsilateral stroke, any stroke, and transient ischemic attacks compared to patients in the DAPT group. The mortality rate was higher at one-year in the alternative cohort (4.7% vs. 7.0%, P<0.01). The use of alternate medication regimens was associated with increased odds of stroke and composite outcome of in-hospital stroke/death compared to DAPT. There was also a significant association between alternative medication use and increased odds of in-hospital transient ischemic attack, immediate stent occlusion, and return to the operating room. At one year, there was no significant difference in the incidence of stroke between the two groups. However, the use of alternate regimens was associated with higher one-year of mortality after multivariable adjustment.

CONCLUSION: Patients not maintained on DAPT after TCAR experienced increased risk of stroke and death in the perioperative and follow-up periods. Increased surgeon vigilance is required to ensure compliance with dual antiplatelets as recommended.