Transcarotid Revascularization Outcomes Are Not Affected by the Choice of Antiplatelet with Aspirin

Abstract

Over one-third of transcarotid revascularization (TCAR) patients demonstrate mild to severe resistance to clopidogrel resulting in an increase in hematologic testing and potential healthcare costs. This investigation was completed to determine if the choice of the second antiplatelet in addition to aspirin affected perioperative outcomes. Consecutive carotid stenting procedures identified from the Vascular Quality Initiative (VQI) from January 2016 to September 2016 were captured. We excluded patients with nonatherosclerotic disease, intracranial disease, and tandem lesions. Two cohorts of patients maintained on dual antiplatelet therapy were compared consisting of aspirin + clopidogrel (AC) and aspirin + prasugrel/ticagrelor (APT). A 1:1 propensity score match including procedure characteristics, age, gender, race, symptomatic status, diabetes, coronary artery disease, prior coronary artery bypass grafting/percutaneous coronary intervention, congestive heart failure, chronic obstructive pulmonary disease, dialysis, smoking status, prior ipsilateral or contralateral coronary artery stenting/carotid endarterectomy, contralateral occlusion, preoperative anticoagulation, urgency, protamine use, and physician case volume was completed to compare perioperative results. Within the specified study period, we captured 38,813 carotid stenting patients on AC and 2346 patients maintained on APT (Table I). Of the AC patients, 25,293 received TCAR while the remaining 13,520 underwent transfemoral stenting. Similarly, 1308 APT patients underwent TCAR and 1038 received transfemoral stenting. Before propensity matching, the crude results noted that APT patients were more likely to experience in-hospital mortality (0.5% vs 1.1%; P < .01), but there was no difference in ipsilateral stroke (1.2% vs 1.1%; P = .62), any stroke (1.5% vs 1.4%; P = .84), or myocardial infarction (MI) (0.5% vs 0.7%; P = .31). After adjustment with our propensity match (Table II), 2047 unique subject pairs were generated. There was no statistical difference with respect to in-hospital mortality (0.6% vs 0.9%; P = .30), ipsilateral stroke (1.4% vs 1.0%; P = .41), any stroke (1.5% vs 1.3%; P = .85), MI (0.8% vs 0.8%; P = .84), or stent thrombosis (0.1% vs 0.3%; P = .18). Additionally, there was no difference in the combined outcomes of stroke/death (1.9% vs 2.0%; P = .63) or stroke/death/MI (2.6% vs 2.7%; P = .74). As testing for antiplatelet resistance has become more prominent in the last several years, we evaluated and noted no variability between study groups before or after a procedure date in 2019. No difference in perioperative stroke, death, and/or stent occlusion are noted after TCAR in patients maintained on AC compared to APT. Therefore, routine testing for clopidogrel resistance is an unnecessary healthcare cost which can be eliminated.Table IACAPTP valuen = 38,813 (94.3)2346 (5.7)Prasugrel346 (14.75)Ticagrelor2000 (85.2)Procedure<.001 Transcarotid artery revascularization25,293 (65.2)1308 (55.7) Transfemoral carotid artery stenting13,520 (34.8)1038 (44.3)Surgery year<.001 2016706 (1.8)37 (1.6) 20173044 (7.8)139 (5.9) 20184666 (12.0)199 (9.5) 20197066 (18.2)379 (16.2) 20207560 (19.5)457 (19.5) 20219836 (25.3)716 (30.5) September 20225935 (15.3)419 (17.9)AC, Aspirin + clopidogrel; APT, aspirin + prasugrel/ticagrelor. Open table in a new tab Table IIBefore PSM (crude outcomes)1:1 PSM (adjusted outcomes)aACAPTP valueACAPTOR (95% CI)bP valuen = 38,813 (94.3)2346 (5.7)n = 2047n = 2047In-hospital outcomes Death204 (0.5)25 (1.1)<0.0113 (0.6)19 (0.9)1.49 (0.70-3.18).30 Ipsilateral stroke457 (1.2)25 (1.1)0.6229 (1.4)21 (1.0)0.77 (0.42-1.43).41 Stroke549 (1.45)32 (1.40)0.8430 (1.5)27 (1.3)0.94 (0.53-1.67).85 MI204 (0.5)16 (0.7)0.3117 (0.8)16 (0.8)0.93 (0.45-1.91).84 Stroke/death680 (1.8)50 (2.1)0.1838 (1.9)41 (2.0)1.13 (0.69-1.83).63 Stroke/death/MI844 (2.2)65 (2.8)0.0653 (2.6)56 (2.7)1.08 (0.70-1.65).74 Bleeding requiring intervention229 (0.6)15 (0.6)0.7611 (0.5)14 (0.7)1.28 (0.56-2.84).54 Immediate restenosis/occlusion63 (0.2)7 (0.3)0.122 (0.1)6 (0.3)3.0 (0.60-14.8).18AC, Aspirin + clopidogrel; APT, aspirin + prasugrel/ticagrelor; CI, confidence interval; MI, myocardial infarction; OR, odds ratio; PSM, propensity score matching.Values are number (%) unless otherwise stated.aNo interaction between antiplatelet regimen and type of procedure in predicting outcome and between antiplatelet regimen and surgeries performed before or after 2019 (P > .10). Open table in a new tab