Bivalirudin for Carotid Artery Stenting

Abstract

In the past decade, carotid artery stenting (CAS) has been carefully studied as a treatment for symptomatic and asymptomatic carotid artery stenosis. In the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) trial, it was shown that the composite outcome of death, stroke, or myocardial infarction is similar for CAS versus carotid endarterectomy when performed by experienced operators.1 During this time period, significant advances have been made with regards to patient selection and procedural techniques.2 In addition, there have been improvements in embolic protection and stent technology. With these advancements, CAS outcomes have continued to improve with a low rate of periprocedural adverse events observed in numerous single-center and multicenter studies.3–5 Article see p 131 In comparison with recent advances in CAS technology, intraprocedural anticoagulation during CAS has been relatively understudied. The initial randomized studies of CAS, including Stenting and Angioplasty with Protection in Patients at High-Risk for Endarterectomy, Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S), Stent-Supported Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy (SPACE), and the International Carotid Stenting Study (ICSS). all used heparin for adjunctive pharmacotherapy.6–9 In the CREST trial, patients randomized to CAS could be treated with either heparin (86%) or bivalirudin (14%).1 Most of the current evidence for CAS is, therefore, based on using heparin as the intraprocedural anticoagulant. The current societal guidelines for CAS do not make a specific recommendation regarding periprocedural anticoagulation but state that either heparin or bivalirudin may be used.10 A direct thrombin inhibitor, such as bivalirudin, could have significant advantages as an anticoagulant during CAS. Bivalirudin can be administered as weight-based infusion with minimal intraprocedural monitoring and predictable pharmacokinetics. In comparison, heparin has variable between-person pharmacokinetics, and the correct dose of heparin for the goal level of …