Antiplatelet and anticoagulant therapy in carotid endarterectomies

Czech version

Authors: M. Orlický ^1,2; P. Vachata ¹; P. Waldauf ³ ; M. Sameš ¹
Authors‘ workplace: Neurochirugická klinika UJEP a Masarykova nemocnice, o. z., Krajská zdravotní, a. s., Ústí nad Labem ¹; Neurochirurgická klinika UNLP, Košice ²; Klinika anesteziologie a resuscitace FN Královské Vinohrady, Praha ³
Published in: Cesk Slov Neurol N 2018; 81(4): 444-449
Category: Original Paper
doi: https://doi.org/10.14735/amcsnn2018444

Overview

Aim:
The influence of antiplatelet agents and anticoagulants on hemorrhagic complications and the development of ischaemic brain lesions during carotid endarterectomies (CEAs) was studied.

Methods:
During 559 CEAs antithrombotic therapy, as administrated by a referral doctor, was kept. The influence of antithrombotic therapy on the: 1. incidence of wound hematoma; 2. incidence of symptomatic intracerebral hematoma after CEA; 3. length of hospital stay; 4. incidence of new brain ischaemic lesions were studied.

Results:
In total, wound hematoma was found in 43 (7.69%) cases. Of those there were: 1. 2.94% in „no antithrombotic“ group; 2. 5.18% (p = 0.55) in the acetylsalicylic acid (ASA)/ASA + derivates group; 3. 18.36% (p = 0.008) in clopidogrel group; 4. 0% in ticlopidin group; 5. 20% = 0.022) in low molecular weight heparin (LMWH) group; 6. 19.05% (p = 0.026) in LMWH + ASA group; 7. 36,36% (p = 0.003) in clopidogrel + ASA group. Incidence of symptomatic intracerebral hematoma after CEA was 0.89% in five cases. The mean length of hospital stay was 4.7 days for uncomplicated cases, 5.1 days for cases with hematoma without reoperation and 7.2 days for cases with hematoma with reoperation. Incidence of new ischaemic lesions after CEA was 10.91%, not related to antithrombotic therapy (p > 0.18).

Conclusion:
Clopidogrel, LMWH and LMWH + ASA groups showed app. 4 times higher risk of wound hematoma, dual antiplatelet therapy 5.5 times higher compared to ASA therapy only. Therefore, their use preoperatively in CEA should be restricted for cases of symptomatic stenosis with high recurrent risk of stroke. No influence of antithrombotics on the incidence of new ischaemic brain lesions during CEA was showed.

Key words:
antiplatelet therapy – anticoagulants – wound hematoma – ischaemic brain lesions – carotid endarterectomy

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manuscript met the ICMJE “uniform requirements” for biomedical papers.

Sources

1. Liu Q, Dang DS, Chen YF et al. The influence of omeprazole on platelet inhibition of clopidogrel in various CYP2C19 mutant alleles. Genet Test Mol Biomarkers 2012; 16(11): 1293– 1297. doi: 10.1089/ gtmb.2012.0119.

2. Duck B. FDA gives plavix a 6 month extension-patent now expires on may 17 2012-in Europe patent expired in 2009. [online]. Available from URL: http:/ / ducknetweb.blogspot.com/ 2011/ 01/ fda-gives-plavix-6-month-extension.html.

3. Fleming MD, Stone WM, Scott P et al. Safety of carotid endarterectomy in patients concurrently on clopidogrel. Ann Vasc Surg 2009; 23(5): 612– 615. doi: 10.1016/ j.avsg.2009.06.004.

4. Wait SD, Abla AA, Killory BD et al. Safety of carotid endarterectomy while on clopidogrel (Plavix). Clinical article. J Neurosurg 2010; 113(4): 908– 912. doi: 10.3171/ 2009.12.JNS09707.

5. Ferguson GG, Eliasziw M, Barr HW et al. The North American Symptomatic Carotid Endarterectomy Trial: surgical results in 1415 patients. Stroke 1999; 30(9): 1751– 1758.

6. Halliday A, Harrison M, Hayter E et al. 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial. The Lancet 2010; 376(9746): 1074– 1084. doi: 10.1016/ S0140-6736(10)61197-X.

7. European Carotid Surgery Trialists‘ Collaborative Group. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). The Lancet 1998; 351(9113): 1379– 1387.

8. Sameš M, Provazníková E, Cihlář F et al. Perisurgical monitoring of activated coagulation time in carotid endarterectomy. Cesk Slov Neurol N 2011; 74/ 107(3): 325– 329.

9. Loftus CM (ed). Anticoagulation and hemostasis in neurosurgery. Basel: Springer 2016.

10. Orlický M, Vachata P, Bartoš R et al. Skrat u karotických endarterektomií zvyšuje riziko ischemického iktu. Cesk Slov Neurol N 2015; 78/ 111(2): 163– 166. doi: 10.14735/ amcsnn2015163.

11. Bonati LH, Jongen LM, Haller S et al. New ischaemic brain lesions on MRI after stenting or endarterectomy for symptomatic carotid stenosis: a substudy of the International Carotid Stenting Study (ICSS). Lancet Neurol 2010; 9(4): 353– 362. doi: 10.1016/ S1474-4422(10)70057-0.

12. Lacroix V, Hammer F, Astarci P et al. Ischemic cerebral lesions after carotid surgery and carotid stenting. Eur J Vasc Endovasc Surg 2007; 33(4): 430– 435. doi: 10.1016/ j.ejvs.2006.11.012.

13. Szabo K, Kern R, Gass A et al. Acute stroke patterns in patients with internal carotid artery disease a diffusion--weighted magnetic resonance imaging study. Stroke 2001; 32(6): 1323– 1329.

14. AHFS DI Essentials. Drugs.com: Aspirin. [online]. Available from URL: https:/ / www.drugs.com/ monograph/ aspirin.html.

15. Catella F, Healy D, Lawson JA et al. 11-Dehydrothromboxane B2: a quantitative index of thromboxane A2 formation in the human circulation. Proc Natl Acad Sci U S A 1986; 83(16): 5861– 5865.

16. Gouya G, Arrich J, Wolzt M et al. Antiplatelet treatment for prevention of cerebrovascular events in patients with vascular diseases: a systematic review and meta-analysis. Stroke 2014; 45(2): 492– 503. doi: 10.1161/ STROKEAHA.113.002590.

17. Diener HC, Bogousslavsky J, Brass LM 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(9431): 331– 337. doi: 10.1016/ S0140-6736(04)16721-4.

18. Šaňák D, Neumann J, Tomek A et al. Guidelines for recanalization therapy of acute cerebral infarction – version 2016. Cesk Slov Neurol N 2016; 79/ 112(2): 231– 234.

19. European Stroke Initiative Executive Committee, EUSI Writing Committee, Olsen TS et al. European stroke initiative recommendations for stroke management-update 2003. Cerebrovasc Dis 2003; 16(4): 311– 337. doi: 10.1159/ 000072554.

20. Brown DG, Wilkerson EC, Love WE. A review of traditional and novel oral anticoagulant and antiplatelet therapy for dermatologists and dermatologic surgeons. J Am Acad Dermatol 2015; 72(3): 524– 534. doi: 10.1016/ j.jaad.2014.10.027.

21. Kalita Z. Akutní cévní mozkové příhody: diagnostika, patofyziologie, management. Praha: Maxdorf 2006: 423– 434.

22. Hankey GJ, Sudlow CL, Dunbabin DW. Thienopyridine derivatives (ticlopidine, clopidogrel) versus aspirin for preventing stroke and other serious vascular events in high vascular risk patients. Cochrane Database Syst Rev 2000; (2): CD001246.

23. Škoda O, Herzig R, Mikulík R et al. Klinický standard pro diagnostiku a léčbu pacientů s ischemickou cévní mozkovou příhodou a s tranzitorní ischemickou atakou – verze 2016. Cesk Slov Neurol N 2016; 79/ 112(3): 351– 363. doi: 10.14735/ amcsnn2016351.

24. Rothwell PM, Warlow CP. Timing of TIAs preceding stroke: time window for prevention is very short. Neurology 2005; 64(5): 817– 820. doi: 10.1212/ 01.WNL.0000152985.32732.EE.

25. Orlický M, Vachata P, Sameš M. Results of early endarterectomies after transient ischaemic attack. Cesk Slov Neurol N 2015; 78/ 111(5): 550– 554. doi: 10.14735/ amcsnn2015550.

26. Mraček J, Holečková I, Mork J et al. Timing karotické endarterektomie. Cesk Slov Neurol N 2008; 104(4)(71): 414– 421.

27. Sacco RL, Adams R, Albers G et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/ American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Circulation 2006; 113(10): e409– 449.

28. Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC), Members AF, Steg PG et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012; 33(20): 2569– 2619. doi: 10.1093/ eurheartj/ ehs215.

29. Timaran CH, Veith FJ, Rosero EB et al. Intracranial hemorrhage after carotid endarterectomy and carotid stenting in the United States in 2005. J Vasc Surg 2009; 49(3): 623– 628. doi: 10.1016/ j.jvs.2008.09.064.

30. Henderson RD, Phan TG, Piepgras DG et al. Mechanisms of intracerebral hemorrhage after carotid endarterectomy. J Neurosurg 2001; 95(6): 964– 969. doi: 10.3171/ jns.2001.95.6.0964.

31. Moulakakis KG, Mylonas SN, Sfyroeras GS et al. Hyperperfusion syndrome after carotid revascularization. J Vasc Surg 2009; 49(4): 1060– 1068. doi: 10.1016/ j.jvs.2008.11.026.

32. Ogasawara K, Sakai N, Kuroiwa T et al. Intracranial hemorrhage associated with cerebral hyperperfusion syndrome following carotid endarterectomy and carotid artery stenting: retrospective review of 4494 patients. J Neurosurg 2007; 107(6): 1130– 1136. doi: 10.3171/ JNS-07/ 12/ 1130.

33. Wang GJ, Beck AW, DeMartino RR et al. Insight into the cerebral hyperperfusion syndrome following carotid endarterectomy from the national Vascular Quality Initiative. [abstrakt]. J Vasc Surg 2016; 81 (2 Suppl) 29S– 36S: e1– e2. doi: 10.1016/ j.jvs.2015.10.004.

34. Yaghi S, Eisenberger A, Willey JZ. Symptomatic intracerebral hemorrhage in acute ischemic stroke after thrombolysis with intravenous recombinant tissue plasminogen activator: a review of natural history and treatment. JAMA Neurol 2014; 71(9): 1181– 1185. doi: 10.1001/ jamaneurol.2014.1210.

35. Kang BK, Na DG, Ryoo JW et al. Diffusion--weighted MR imaging of intracerebral hemorrhage. Korean J Radiol 2001; 2(4): 183– 191.

36. Linfante I, Llinas RH, Caplan LR et al. MRI features of intracerebral hemorrhage within 2 hours from symptom onset. Stroke 1999; 30(11): 2263– 2267.

37. Ricotta JJ, Aburahma A, Ascher E et al. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg 2011; 54(3): e1– e31. doi: 10.1016/ j.jvs.2011.07.031.

38. Ederle J, Dobson J , Featherstone RL et al. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial. Lancet 2010; 375(9719): 985– 997. doi: 10.1016/ S0140-6736(10)60239-5.

39. Brott TG, Hobson RW, Howard G et al. Stenting versus endarterectomy for treatment of carotid- artery stenosis. N Engl J Med 2010; 363(1): 11– 23. doi: 10.1056/ NEJMoa0912321.

40. Školoudík D, Kuliha M, Hrbáč T et al. Sonolysis in prevention of brain infarction during carotid endarterectomy and stenting (SONOBUSTER): a randomized, controlled trial. Eur Heart J 2016; 37(40): 3096– 3102. doi: 10.1093/ eurheartj/ ehv492