title: Second-generation thienopyridine use is not associated with better early perioperative outcome during carotid stenting.
abstract: OBJECTIVE
  Management of anti-platelet therapy during carotid artery stenting (CAS) is mainly based on indirect evidence from coronary stenting experience. There is common agreement on the use of thienopyridine (mainly second-generation) during CAS, but some patients are unsuitable for clopidogrel treatment and data on the benefit of its use in large CAS populations are lacking. The aim of this study was to investigate whether clopidogrel was associated with reduced perioperative morbidity in patients undergoing CAS.
  
  
  METHODS
  Consecutive patients undergoing CAS for primary carotid stenosis from 2004 to 2009 were reviewed. The independent association of clopidogrel and perioperative morbidity was assessed using multivariable analysis.
  
  
  RESULTS
  A total of 1083 patients were treated (29% females, mean age 71.6 years); 825 (76%) patients were given clopidogrel starting before treatment. Clopidogrel use was associated with a non-significant reduction of perioperative stroke/death (4.3% vs. 2.4%; p = 0.13) and disabling stroke (1.2% vs. 1.0%; p = 1) rates. The non-significant stroke/death difference was similar in symptomatic (5.8% vs. 4.0%, p = 0.37) and asymptomatic (3.7% vs. 1.9%; p = 0.17) patients. After adjusting for demographics, co-morbidities and other therapies with multivariable analysis, clopidogrel use failed to show any significant independent association in decreasing operative risks. The only independent protective factor was use of statins (p = 0.010). The additional use of dual anti-platelet therapy did not add any advantage to the use of clopidogrel alone.
  
  
  CONCLUSIONS
  The suggested benefit of clopidogrel in decreasing the incidence of complications in patients undergoing CAS may be overestimated due to the overlapping effect of other more relevant factors (e.g., pleiotropy and plaque stabilisation from statins). More data and level I evidence are needed to understand which is the best medical management of CAS that will help improve outcomes of the procedure.
authors.affiliation: Vascular and Endovascular Surgery, Hospital S M Misericordia, University of Perugia, Perugia, Italy. plderango@gmail.com
authors.forename: P
authors.initials: P
authors.lastname: De Rango
authors.forename: G
authors.initials: G
authors.lastname: Parlani
authors.forename: L
authors.initials: L
authors.lastname: Romano
authors.forename: F
authors.initials: F
authors.lastname: Verzini
authors.forename: G
authors.initials: G
authors.lastname: Giordano
authors.forename: E
authors.initials: E
authors.lastname: Cieri
authors.forename: M
authors.initials: M
authors.lastname: Barbante
authors.forename: P
authors.initials: P
authors.lastname: Cao
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D017130:Angioplasty / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D058070:Asymptomatic Diseases; D016893:Carotid Stenosis / Q000150:complications / Q000401:mortality / Q000628:therapy*; D016009:Chi-Square Distribution; D000077144:Clopidogrel; D005260:Female; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use; D007558:Italy; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D020521:Stroke / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D013988:Ticlopidine / Q000031:analogs & derivatives* / Q000627:therapeutic use; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine