Cilostazol Reduces Periprocedural Hemodynamic Depression in Carotid Artery Stenting

Abstract

The clinical effects of two different types of antiplatelet drugs, cilostazol and thienopyridine drugs, were compared in patients treated by carotid artery stenting (CAS). Two hundred patients scheduled for CAS were randomized to either cilostazol or a thienopyridine drug (ticlopidine or clopidogrel). The study was conducted in open-label design. Aspirin was also given to all patients. All episodes of periprocedural hemodynamic instability (bradycardia, hypotension) were recorded together with all instances of stroke, cardiac morbidity, and death within 30 days of the procedure. Angiographic followup studies were conducted about 6 months after CAS. Finally, 197 patients were enrolled in this study; 97 were treated with cilostazol (cilostazol group) and 100 with a thienopyridine drug (thienopyridine group). In the 30-day follow-up period, the incidence of stroke, cardiac adverse effects, and death was not significantly different between the 2 groups (cilostazol group 7.2%, thienopyridine group 11.0%; p ＝ 0.85). The incidence of intra-and postprocedural bradycardia was significantly lower in the cilostazol group (cilostazol group 18.6% and 2.1%, thienopyridine group 40.0% and 18.0%, respectively; p º 0.01). Although the incidence of intraprocedural hypotension did not significantly differ between the 2 groups, postprocedural hypotension was significantly lower in the cilostazol group (16.5% vs. 34.0%, p º 0.01). In-stent restenosis on follow-up angiograms was lower in the cilostazol group but not significantly (0% vs. 4.4%, p ＝ 0.12). This small open-label study shows that cilostazol may reduce periprocedural bradycardia and hypotension compared with thienopyridine drugs in patients treated by CAS.

Meta-Analysis of Studies Evaluating the Effect of Cilostazol on Major Outcomes After Carotid Stenting

“…Several studies have concluded that it reduces hypotension and bradycardia during CAS, thus preventing possible complications. 17,48 After analyzing 5 studies with reported 30-day outcomes, we found that the pooled MI/stroke/death rate reached only 3.1%, although 4 trials with reported late events indicated a pooled late rate of 7.9%. In one of the largest registries for CAS, Sakai et al 49 reported the incidence of first adverse events in a cohort of 934 patients undergoing CAS in Japan.…”

“…The basic characteristics of all included patients are presented in Table 2 Four studies [17][18][19]21 were identified to compare basic characteristics between patients treated with cilostazol and those not. The pooled subanalysis of these studies found the groups relatively similar except for dyslipidemia and the use of open cell stents (Table 3).…”

“…Regarding clinical events post CAS, data were adequate for comparison in only 5 trials 16,17,19,21,22 for 30-day outcomes and in 4 trials [17][18][19]21 for outcomes during the followup period. As no heterogeneity was identified, fixed-effect models were utilized.…”

“…Regarding major/minor bleeding, 3 of the studies 17,20,21 did not report any result and 2 studies 16,22 reported null bleeding events after CAS. Only one study 19 reported 7 bleedings overall (6 access site hematomas and 1 hemorrhage due to Regarding the revascularization rate post ISR, only 3 studies 18,19,22 reported a pooled rate of 33 endovascular treatments in 51 cases of ISR (65%) without stratifying the results according to antiplatelet treatment.…”

“…Additionally, the included studies did not report correlations between characteristics of patients and the incidence of outcomes, so that no independent risk factors could be calculated. Finally, when we stratified our analysis based on the type of trials (randomized vs nonrandomized), we observed that Tsutsumi et al 17 (the only randomized trial) found no difference between patient groups concerning ISR and the 30-day and overall MI/stroke/death rates (p=0.12, p=0.72, and p=0.72, respectively). However, this observation justifies the designation of a meta-analysis that includes as many studies as possible, although it underlines the need for new randomized trials to be initiated.…”