VESS21 - Outcomes of Patients on Triple Antithrombotic Therapy versus Single Antiplatelet Therapy Combined with Anticoagulation Agent After Carotid Artery Stenting

Objectives: Carotid artery stenting (CAS) is a well-established intervention for patients with carotid artery disease. The standard post-procedural regimen is dual antiplatelet therapy (DAPT) for at least four weeks; however, patients on chronic anticoagulation (AC) who undergo CAS and receive DAPT are at increased risk for major bleeding events. The optimal antithrombotic strategy in this population remains debated, and outcomes of ticagrelor as a single antiplatelet therapy (SAPT) in combination with AC have not been investigated. Our study aimed to evaluate adverse outcomes associated with triple therapy—specifically AC combined with aspirin (ASA) and ticagrelor. By doing so, we sought to assess the feasibility of shifting toward a SAPT agent such as ticagrelor combined with AC to potentially reduce bleeding complications. This pilot study was conducted to generate preliminary insights and serve as a foundation for a larger, more comprehensive investigation.

Methods: This retrospective, single-institution study spanning nine years evaluated clinical outcomes in patients undergoing CAS who received either AC plus DAPT or AC plus SAPT. Patients were grouped by antithrombotic regimen, with additional subgroup analyses focusing on ticagrelor-based triple and double therapy. Thirty-day outcomes included minor and major bleeding events, ischemic and hemorrhagic stroke, myocardial infarction, and all-cause mortality. Platelet reactivity units (PRUs) were recorded preoperatively, postoperatively, and at follow-up. The study was approved by the institutional review board.

Results: Of 491 patients undergoing CAS, 85 met inclusion criteria: 33 received triple therapy and 52 received AC + SAPT. Among triple-therapy patients, 15 received ticagrelor; three experienced major complications (anemia requiring transfusion, upper GI bleed requiring embolization, and hemorrhagic stroke). Among the remaining 18 on ASA, clopidogrel, and AC, four complications occurred (anemia requiring transfusion, GI bleed requiring medication cessation, stent thrombosis with ischemic stroke, and hemorrhagic stroke). Of the AC + SAPT group, 20 patients received ticagrelor and two complications occurred (retroperitoneal hematoma and subdural hematoma). Among the 32 patients on ASA or clopidogrel with AC, four complications were observed (two GI bleeds requiring embolization, one retroperitoneal hematoma, and one unrelated death)

Conclusions: In patients on chronic AC undergoing CAS, adding DAPT is common but may increase adverse events. Our preliminary experience suggests that SAPT with AC does not raise the risk of stent thrombosis or stroke and may reduce bleeding. Multi-center studies are needed to further evaluate the safety of ticagrelor as a single antiplatelet agent in this population.