Optimizing TCAR Antithrombotic Regimens for Patients on Chronic Anticoagulation.

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.