Considerations for Antiplatelet Management of Carotid Stenting in the Setting of Mechanical Thrombectomy: A Delphi Consensus Statement

Abstract

BACKGROUND AND PURPOSE: There are only few data and lack of consensus regarding antiplatelet management for carotid stent placement in the setting of endovascular stroke treatment. We aimed to develop a consensus-based algorithm for antiplatelet management in acute ischemic stroke patients undergoing endovascular treatment and simultaneous emergent carotid stent placement. MATERIALS AND METHODS:We performed a literature search and a modified Delphi approach used Web-based questionnaires that were sent in several iterations to an international multidisciplinary panel of 19 neurointerventionalists from 7 countries. The first round included open-ended questions and formed the basis for subsequent rounds, in which closed-ended questions were used. Participants continuously received feedback on the results from previous rounds. Consensus was defined as agreement of $70% for binary questions and agreement of $50% for questions with .2 answer options. The results of the Delphi process were then summarized in a draft manuscript that was circulated among the panel members for feedback.RESULTS: A total of 5 Delphi rounds were performed. Panel members preferred a single intravenous aspirin bolus or, in jurisdictions in which intravenous aspirin is not available, a glycoprotein IIb/IIIa receptor inhibitor as intraprocedural antiplatelet regimen and a combination therapy of oral aspirin and a P2Y12 inhibitor in the postprocedural period. There was no consensus on the role of platelet function testing in the postprocedural period.CONCLUSIONS: More and better data on antiplatelet management for carotid stent placement in the setting of endovascular treatment are urgently needed. Panel members preferred intravenous aspirin or, alternatively, a glycoprotein IIb/IIIa receptor inhibitor as an intraprocedural antiplatelet agent, followed by a dual oral regimen of aspirin and a P2Y12 inhibitor in the postprocedural period.ABBREVIATIONS: EVT ¼ endovascular treatment; GPIIb/IIIa ¼ glycoprotein IIb/IIIa C urrently, it is not clear whether and when carotid stent placement should be performed in patients with acute ischemic stroke with extracranial carotid stenosis, occlusion, or unstable plaques undergoing endovascular treatment (EVT), but there is no doubt that carotid stent placement is necessary in some cases. 1 Numerous studies and review articles discuss the benefits and

Comparing Endovascular Treatment Methods in Acute Ischemic Stroke Due to Tandem Occlusion Focusing on Clinical Aspects

“…The intravenous antiplatelet therapy directly prior to carotid stenting may be the explanation of the relatively higher hemorrhage events, however, it is necessary to prevent acute stent thrombosis. Currently only few data are available for periprocedural antiplatelet management of acute carotid stenting during EVT [22]. Based on the latest antiplatelet Delphi consensus, aspirin IV (500 mg bolus) should be used as the first-line agent prior to carotid stenting [22].…”

“…Currently only few data are available for periprocedural antiplatelet management of acute carotid stenting during EVT [22]. Based on the latest antiplatelet Delphi consensus, aspirin IV (500 mg bolus) should be used as the first-line agent prior to carotid stenting [22]. Although Da Ros et al identified potential predictors for sICH as the higher intraprocedural heparin dosage, the initial ASPECTS ≤7 and the MT needs more than one attempt for complete recanalization [26].…”

“…After the exclusion of the hemorrhagic transformation on the 24-h control image, dual antiplatelet therapy with oral acetylsalicylic acid at 100 mg and clopidogrel at 75 mg daily was initiated in the stenting group and continued for 3 months. As secondary prevention, BAO patients received anti-platelet monotherapy with oral acetylsalicylic acid at 100 mg lifelong [22].…”

P2Y12 inhibitors for the neurointerventionalist

“… 16 IV administration of aspirin or a GPIIb/IIIa agent, such as eptifibatide or tirofiban, can be considered and this can be switched to clopidogrel post-procedurally. 17 , 18 However, there is heterogeneity in practice and a lack of reliable high-quality evidence to make specific antiplatelet recommendations for this clinical context at present.…”

Antithrombotic therapies for neurointerventional surgery: a 2021 French comprehensive national survey

“…Numerous antithrombotic drugs are now available, and some were recently approved 4. Clinical situations faced by neurointerventionists are very diverse and sometimes require balancing hemorrhagic and ischemic risks 5–7. The European and American Cardiology Societies have both released recommendations guiding the use of antiplatelet medications during percutaneous procedures 8 9.…”