Safety of direct oral anticoagulant - and antiplatelet therapy in patients with atrial fibrillation treated by carotid artery stenting

      Abstract

      Background

      The periprocedural administration of dual antiplatelet therapy has been recommended in patients treated by carotid artery stenting. However, some patients with concurrent disease have been prescribed anticoagulants. We compared the post-operative incidence of hemorrhagic and thromboembolic events in two patient groups treated by different regimens of multi-antithrombotic agents.

      Methods

      As our 31 patients had a history of nonvalvular atrial fibrillation, they had received anticoagulants; they were also treated with aspirin and clopidogrel before carotid artery stenting. The prior anticoagulant therapy was continued in 17 patients and they received vitamin K antagonist plus dual antiplatelet therapy after the procedure (group 1). Other 14 patients underwent direct oral anticoagulant plus aspirin or clopidogrel (group 2). Post-procedural hemorrhagic and thromboembolic events were compared between two groups.

      Results

      Carotid artery stenting was angiographically successful in all patients. Complications were encountered in two group 1 patients. Post-operative image revealed a silent subarachnoid hemorrhage in one. The other presented with superior mesenteric artery occlusion 6 months after the procedure. No hemorrhagic or thromboembolic events occurred in group 2.

      Conclusion

      We concluded that the administration of a direct oral anticoagulant plus an antiplatelet agent reduced the risk for periprocedural hemorrhagic and embolic events in patients with concurrent nonvalvular atrial fibrillation who underwent carotid artery stenting.

      Key words

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      References

        • Bonati L.H.
        • Dobson J.
        • Featherstone R.L.
        • et al.
        Long-term outcomes after stenting versus endarterectomy for treatment of symptomatic carotid stenosis: the International Carotid Stenting Study (ICSS) randomised trial.
        Lancet. 2015; 385: 529-538
        • Brott T.G.
        • Howard G.
        • Roubin G.S.
        • et al.
        Long-term results of stenting versus endarterectomy for carotid-artery stenosis.
        N Engl J Med. 2016; 374: 1021-1031
        • Rosenfield K.
        • Matsumura J.S.
        • Chaturvedi S.
        • et al.
        Randomized trial of stent versus surgery for asymptomatic carotid stenosis.
        N Engl J Med. 2016; 374: 1011-1020
        • Yadav J.S.
        • Wholey M.H.
        • Kuntz R.E.
        • et al.
        Protected carotid-artery stenting versus endarterectomy in high-risk patients.
        N Engl J Med. 2004; 351: 1493-1501
        • Toyoda K.
        • Yasaka M.
        • Iwade K.
        • et al.
        Dual antithrombotic therapy increases severe bleeding events in patients with stroke and cardiovascular disease: a prospective, multicenter, observational study.
        Stroke. 2008; 39: 1740-1745
        • Connolly S.J.
        • Ezekowitz M.D.
        • Yusuf S.
        • et al.
        Dabigatran versus warfarin in patients with atrial fibrillation.
        N Engl J Med. 2009; 361: 1139-1151
        • Giugliano R.P.
        • Ruff C.T.
        • Braunwald E.
        • et al.
        Edoxaban versus warfarin in patients with atrial fibrillation.
        N Engl J Med. 2013; 369: 2093-2104
        • Granger C.B.
        • Alexander J.H.
        • McMurray J.J.
        • et al.
        Apixaban versus warfarin in patients with atrial fibrillation.
        N Engl J Med. 2011; 365: 981-992
        • Patel M.R.
        • Mahaffey K.W.
        • Garg J.
        • et al.
        Rivaroxaban versus warfarin in nonvalvular atrial fibrillation.
        N Engl J Med. 2011; 365: 883-891
        • Cannon C.P.
        • Bhatt D.L.
        • Oldgren J.
        • et al.
        Dual antithrombotic therapy with dabigatran after PCI in atrial fibrillation.
        N Engl J Med. 2017; 377: 1513-1524
        • Gibson C.M.
        • Mehran R.
        • Bode C.
        • et al.
        Prevention of bleeding in patients with atrial fibrillation undergoing PCI.
        N Engl J Med. 2016; 375: 2423-2434
        • Lopes R.D.
        • Heizer G.
        • Aronson R.
        • et al.
        Antithrombotic therapy after acute coronary syndrome or PCI in atrial fibrillation.
        N Engl J Med. 2019; 380: 1509-1524
        • North American Symptomatic Carotid Endarterectomy Trial Collaborators
        Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis.
        N Engl J Med. 1991; 325: 445-453
        • Hawkins B.M.
        • Kennedy K.F.
        • Giri J.
        • et al.
        Pre-procedural risk quantification for carotid stenting using the CAS score: a report from the NCDR CARE registry.
        J Am Coll Cardiol. 2012; 60: 1617-1622
        • Qureshi A.I.
        • Chaudhry S.A.
        • Qureshi M.H.
        • et al.
        Rates and predictors of 5-year survival in a national cohort of asymptomatic elderly patients undergoing carotid revascularization.
        Neurosurgery. 2015; 76 (discussion 40-41): 34-40
        • Sposato L.A.
        • Suárez A.
        • Jáuregui A.
        • et al.
        Intraoperative hypotension, new onset atrial fibrillation, and adverse outcome after carotid endarterectomy.
        J Neurol Sci. 2011; 309: 5-8
        • Dewilde W.J.
        • Oirbans T.
        • Verheugt F.W.
        • et al.
        Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial.
        Lancet. 2013; 381: 1107-1115
        • Diener H.C.
        • Bogousslavsky J.
        • Brass L.M.
        • et al.
        Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial.
        Lancet. 2004; 364: 331-337
        • Schroeder T.
        • Sillesen H.
        • Sørensen O.
        • et al.
        Cerebral hyperperfusion following carotid endarterectomy.
        J Neurosurg. 1987; 66: 824-829
        • Mackman N.
        The role of tissue factor and factor VIIa in hemostasis.
        Anesth Analg. 2009; 108: 1447-1452
        • Hagii J.
        • Tomita H.
        • Metoki N.
        • et al.
        Characteristics of intracerebral hemorrhage during rivaroxaban treatment: comparison with those during warfarin.
        Stroke. 2014; 45: 2805-2807
        • Vranckx P.
        • Lewalter T.
        • Valgimigli M.
        • et al.
        Evaluation of the safety and efficacy of an edoxaban-based antithrombotic regimen in patients with atrial fibrillation following successful percutaneous coronary intervention (PCI) with stent placement: rationale and design of the ENTRUST-AF PCI trial.
        Am Heart J. 2018; 196: 105-112
        • Borensztajn K.
        • Peppelenbosch M.P.
        • Spek C.A.
        Factor Xa: at the crossroads between coagulation and signaling in physiology and disease.
        Trends Mol Med. 2008; 14: 429-440
        • Spronk H.M.
        • de Jong A.M.
        • Crijns H.J.
        • et al.
        Pleiotropic effects of factor Xa and thrombin: what to expect from novel anticoagulants.
        Cardiovasc Res. 2014; 101: 344-351
        • Borensztajn K.
        • Spek C.A.
        Blood coagulation factor Xa as an emerging drug target.
        Expert Opin Ther Targets. 2011; 15: 341-349
        • Yasuda S.
        • Kaikita K.
        • Akao M.
        • et al.
        Antithrombotic therapy for atrial fibrillation with stable coronary disease.
        N Engl J Med. 2019; 381: 1103-1113

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