Abstract
Carotid endarterectomy is usually preferred over carotid artery stenting (CAS) for patients with atrial fibrillation (AF). We present our experience with short-course periprocedural triple antithrombotic therapy in 32 patients aged >18 years with nonvalvular AF undergoing CAS. There were no deaths, cardiac events, embolic strokes, hyperperfusion syndrome, intracranial hemorrhage, or stent thrombosis within 30 days. Transient intraprocedural hemodynamic instability in 15/32 (47%) and prolonged instability in 4/32 (13%) was managed conservatively. At a mean 16-month follow-up, there were no new neurological events or deterioration. Mean stenosis was reduced from 78.0% ± 9.7% to 17.3% ± 12.2%. This retrospective study included patients AF who were symptomatic (minor stroke (NIHSS ≤ 5)/TIA) with ICA stenosis >50%, or asymptomatic under DOAC therapy with carotid stenosis >80%, who underwent CAS from 6/2014–10/2020. Patients received double antiplatelets and statins. Antiplatelet therapy effectiveness was monitored. Stenting was performed when P2Y12 reaction units (PRU) were <150. DOACs were discontinued 48 h before angioplasty; one 60 mg dose of subcutaneous enoxaparin was administered in lieu. DOAC was restarted 12–24 h after intervention. Patients were discharged under DOAC and one nonaspirin antiplatelet. 32 patients on DOAC were included (26 male, mean age 71). 19 (59.4%) presented with stroke (ICA stenosis-related in 14); 13 (40.6%) were asymptomatic. Stents were deployed under filter protection following pre-angioplasty; post-angioplasty was performed at least once in 12 patients (37.5%). Our experience suggests that CAS can be safely performed in selected patients with CAS and AF requiring DOAC. The role of CAS in AF patients under DOAC warrants study in rigorous trials.
Highlights
Carotid artery stenting (CAS) is usually withheld in favor of carotid endarterectomy for patients with atrial fibrillation (AF), primarily because of the need for double antiplatelet therapy to prevent stent-related thromboembolic complications, and anticoagulation with direct oral anticoagulants (DOAC) to prevent cardioembolic stroke during stenting
The degree of carotid stenosis was determined based on North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria [10]
(11%, 26 males and 6 females) with carotid stenosis and nonvalvular AF who were under anticoagulant therapy satisfied inclusion and exclusion criteria
Summary
Carotid artery stenting (CAS) is usually withheld in favor of carotid endarterectomy for patients with atrial fibrillation (AF), primarily because of the need for double antiplatelet therapy to prevent stent-related thromboembolic complications, and anticoagulation with direct oral anticoagulants (DOAC) to prevent cardioembolic stroke during stenting. Data on triple antithrombotic therapy after carotid stenting is lacking, but this strategy has been studied extensively by interventional cardiologists [3,4,5], since a significant proportion of patients with AF undergo percutaneous coronary interventions (PCI) [5]. When these patients undergo PCI or have an acute coronary syndrome, DOAC and double antiplatelet therapy (DAT), usually with aspirin and clopidogrel, have been combined. In the absence of guidelines, these regimens are determined for individual patients based on case-by-case assessment of three competing risks: cardioembolic stroke, coronary ischemic events, and bleeding [5]
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