Study suggests superiority of stenting over surgery in patients with ongoing oral anticoagulant therapy

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Gianluca Faggioli, associate professor of Vascular Surgery at the University of Bologna, Italy, presented results of a study investigating the outcomes of different carotid revascularisation approaches in patients with ongoing oral anticoagulation therapy.

“Few studies have addressed the influence of the management of chronic oral anticoagulant therapy in patients undergoing carotid revascularisation,” Faggioli said. “The aim of our study is to assess the outcome of patients undergoing endarterectomy with anticoagulant therapy converted to heparin, which is the standard approach in most centres,  patients undergoing carotid artery stenting with  the oral anticoagulant therapy unmodified, compared with those with no anticoagulant therapy undergoing either type of carotid revascularisation.”

Perioperative results of all patients submitted to carotid endarterectomy and stenting in a five-year period have been analysed by Chi-square and Fisher’s tests in terms of stroke, death, myocardial infarction and haematoma of the access site requiring surgical evacuation.
In 1,006 carotid procedures (512 carotid endarterectomies [50.8%] and 494 stenting procedures [49.2%]), overall perioperative complications were: 20 strokes (1.9%), four deaths (0.4%), three myocardial infarctions (0.3%) and 14 haematomas (1.4%).

 

Anticoagulant therapy converted to heparin was significantly associated with a higher complication rate in endarterectomy (Table 1).

 

 

 

Overall CEA

# 512

CEA in OAT converted to heparin

# 22

CEA in NOAT

# 490

 p

 

n (%)

n (%)

n (%)

 

Events

 

 

 

 

Stroke

8 (1.6)

3 (13.6)

5 (1.0)

0.001

Death

3 (0.6)

1 (4.5)

2 (0.4)

0.01

Myocardial infarction

3 (0.6)

0 (0.0)

3 (0.6)

0.71

Haematoma

10 (1.9)

2 (9.0)

8 (0.9)

0.01

Composite events

 

 

 

 

Stroke/death

11 (2.1)

4 (18.1)

7 (1.4)

0.001

Stroke/death/MI

14 (2.7)

4 (18.1)

10 (2.0)

0.001

Stroke/death/MI/haematoma

23 (4.5)

6 (27.2)

18 (3.6)

0.001

 Table 1   CEA = Carotid endarterectomy, OAT= Oral anticoagulation therapy, NOAT = Non-anticoagulation therapy 

 

In carotid artery stenting patients, results were similar in the anticoagulation therapy vs. the non-anticoagulation therapy group. The study has also shown that oral angicoagulation therapy patients who underwent carotid artery stenting had better results compared with anticoagulant therapy converted to heparin patients who underwent endarterectomy (Table 2).

 

 

CEA in OAT converted to heparin

CAS in unmodified OAT

p

 

# 22 (%)

# 20 (%)

 

Perioperative events

 

 

 

Stroke

3 (13.6)

0 (0)

0.20

Death

1 (4.5)

0 (0)

1.0

Myocardial infarction (MI)

0 (0)

0 (0)

Haematoma

2 (9.0)

0 (0)

0.48

Composite events

 

 

 

Stroke/death

4 (18.1)

0 (0)

0.10

Stroke/death/MI

4 (18.1)

0 (0)

0.10

Stroke/death/MI/haematoma

6 (27.2)

0 (0)

0.02

Table 2   CEA = Carotid endarterectomy, OAT= Oral anticoagulation therapy,  CAS = Carotid artery stenting

 

 

“Chronic oral anticoagulant therapy management significantly influences the results of carotid revascularisation,” Faggioli stated. “Carotid artery stenting under unmodified anticoagulation therapy had a significantly better outcome compared to endarterectomy with chronic oral anticoagulant therapy switched to heparin in our group of patients. Although the number of patients under oral anticoagulation therapy was small, our study suggests that carotid revascularisation strategies should favour stenting rather than surgery in this type of patients,” he concluded.

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