Alternatives to Dual Antiplatelet Therapy Are Not Recommended After Transcarotid Revascularization

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Inadequate compliance with dual antiplatelet therapy (DAPT) in the setting of transcarotid revascularization (TCAR) is often encountered due to poor tolerance, bleeding, or need for anticoagulation. We aim to define the risks associated with the replacement of DAPT for an alternate medication regimen. All patients undergoing TCAR in the Vascular Quality Initiative from September 2016 to March 2022 were included into the study population comparing DAPT to alternative medication regimens via univariable, multivariable, and propensity score matching techniques. We captured 29,802 total TCAR procedures consisting of 24,651 (82.7%) maintained on DAPT and 5151 (17.3%) on alternative regimens (Table I). Patients on alternative medications were more likely to experience in-hospital death (0.4% vs 0.7%; P < .01), ipsilateral stroke (1.0% vs 1.7%; P < .01), any stroke (1.2% vs 1.9%; P < .01), and transient ischemic attack (0.4% vs 0.7%; P < .01). Additionally, the mortality rate was higher at 1-year postprocedure in the alternative cohort (4.7% vs 7.0%; P < .01). On the multivariable analysis, we noted a higher risk of in-hospital death (odds ratio [OR], 1.5; 95% confidence interval [CI], 0.9-2.5; P < .01), ipsilateral stroke (OR, 1.5; 95% CI, 1.2-2.0) and transient ischemic attack (OR, 1.7; 95% CI, 1.2-2.4) in the alternate medication group. The higher incidence of mortality at one-year postprocedure persisted as well despite adjustment (OR, 1.4; 95% CI, 1.2-1.6). A propensity score match with respect to 29 variables generated 4876 unique pairs (Table II). Compared to patients on DAPT, in-hospital ipsilateral stroke was significantly higher in patients receiving alternative antiplatelet regimens (1.7% vs 1.1%, OR, 1.54; 95% CI, 1.10-2.16; P = .01), while no statistically significant difference was noted with respect to mortality (0.6% vs 0.5%; OR, 1.35; 95% CI, 0.72-2.54; P = .35). A composite of stroke/death was also more likely in patients receiving an alternative regimen (2.4% vs 1.7%; OR, 1.47; 95% CI, 1.12-1.93; P = .01). Immediate stent thrombosis (OR, 2.75; 95% CI, 1.16-6.51) and a nonsignificant trend toward increased return to the operating room was more common in the alternative patients. Conversely, the incidence of perioperative myocardial infarction was slightly lower in the alternative regimen group (0.4% vs 0.7%; OR, 0.53; 95% CI, 0.31-0.90; P = .02). At 1 year postprocedure, we observed an increased risk of mortality (hazard ratio, 1.34; 95% CI, 1.11-1.63; P < .01), but not stroke (hazard ratio, 0.52; 95% CI, 0.27-0.99; P = .06), in patients treated with an alternative medication regimen. Increased surgeon vigilance is required to ensure TCAR patients are maintained on DAPT as alternatives are associated with an increased rate of adverse events.Table IPerioperative and 1-year outcomesDAPT (n = 24,651)Alternate regimen (n = 5151)P valueIn-hospital outcomes Death93 (0.4)35 (0.7)<.01 Ipsilateral stroke256 (1.0)85 (1.7)<.01 Stroke299 (1.2)97 (1.9)<.01 Myocardial infarction135 (0.6)19 (0.4).10 Transient ischemic attack108 (0.4)38 (0.7)<.01 Stroke/death355 (1.4)124 (2.4)<.01 Stroke/death/myocardial infarction470 (1.9)140 (2.7)<.01 Length of stay, median (IQR)1 (1-2)1 (1-3)<.01 Postop length of stay >1 day6968 (28.3)1681 (32.6)<.01 Cranial nerve injury61 (0.3)12 (0.3).90 Bleeding requiring intervention180 (0.7)55 (1.1).01 Immediate occlusion35 (0.1)20 (0.4)<.01Return to operating room181 (0.7)58 (1.1)<.01 Reason.48Bleeding162 (89.5)48 (82.8)Occlusion17 (9.4)8 (13.8)Infection1 (0.6)1 (1.7)Pseudoaneurysm1 (0.6)1 (1.7)One-year outcomes Mortality4.7% (4.4-5.0)7.0% (6.2-8.0)<.01 Stroke0.9% (0.8-1.1)0.7% (0.4-1.1).20DAPT, Dual antiplatelet therapy.Values are number (%) unless otherwise indicated. Open table in a new tab Table IIIn-hospital outcomesAlternate therapy vs DAPT (C-Statistic 0.66-0.68)OR [95% CI]P valueDeath1.5 [0.9-2.5].12Ipsilateral stroke1.5 [1.2-2.0]<.01Total stroke1.5 [1.2-1.9]<.01Transient ischemic attack1.7 [1.2-2.4].01Stroke/death1.6 [1.2-2.0]<.01Stroke/death/myocardial infarction1.3 [1.1-1.6].01Bleeding1.3 [1.0-1.8].06Immediate occlusion2.8 [1.6-4.8]<.01Return to operating room1.4 [1.1-2.0].02One-year outcomesHazard ratio [95% CI]Mortality1.4 [1.2-1.6]<.01Stroke0.7 [0.4-1.2].15Stroke/death1.2 [1.0-1.5].03CI, Confidence interval; DAPT, dual antiplatelet therapy; OR, odds ratio.Values are number (%) unless otherwise indicated.Final variables included in the model: age, gender, symptomatic status, diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, end-stage renal disease, active smoking status, prior ipsilateral carotid endarterectomy and carotid artery stenting, contralateral carotid occlusion, elective status, protamine use, and surgeon volume with clustering by institutional centers. Open table in a new tab