Dual Antiplatelet Therapy Prior to Expedited Carotid Surgery Reduces Recurrent Events Prior to Surgery without Significantly Increasing Peri-operative Bleeding Complications.
OBJECTIVE
A daily Rapid-Access TIA Clinic was introduced in 2008, where symptomatic patients were started on 75 mg aspirin + 40 mg simvastatin by the referring doctor, before attending the clinic. Following clinic assessment, patients with 50-99% stenoses were transferred to the vascular unit for carotid endarterectomy (CEA). In two audits (n = 212 patients), the median delay from transfer to the vascular unit to undergoing CEA was 3 days, during which time 28 patients (13%) suffered recurrent neurological events. It was hypothesized that early introduction of dual antiplatelet therapy (by adding clopidogrel 75 mg once parenchymal haemorrhage was excluded in the TIA clinic) might significantly reduce recurrent events between transfer to the surgical unit and undergoing CEA.


METHODS
Prospective audit in 100 consecutive, recently symptomatic patients receiving dual antiplatelet therapy. Endpoints were: prevalence of recurrent events between transfer from the TIA clinic and undergoing CEA; rates of spontaneous embolization prior to undergoing CEA; and prevalence of haemorrhagic complications


RESULTS
The median delay from symptom to CEA was 8 days (IQR 5-15). The median delay between transfer from the TIA clinic to CEA was 3 days (IQR 2-5), during which time three patients (3%) suffered recurrent TIAs. This represents a fivefold reduction compared with previous audit data (OR 4.9, 95% CI 1.5-16.6, p = .01) and was matched by a fourfold reduction in the prevalence of spontaneous embolization from 39/189 (21%) previously to 5/83 (5%) in the current audit (OR 4.1, 95% CI 1.5-10.7, p = .0047). The 30-day death/stroke rate was 1%. There were three haemorrhagic complications: stroke caused by haemorrhagic transformation of an infarct; exploration for neck haematoma; and debridement and skin grafting for spontaneous shin haematoma.


CONCLUSIONS
Early introduction of dual antiplatelet therapy was associated with a significant reduction in recurrent neurological events and spontaneous embolization prior to CEA, without incurring a significant increase in major peri-operative bleeding complications.
Department of Vascular Surgery at Leicester Royal Infirmary, Leicester, UK.
A
A
Batchelder
Department of Vascular Surgery at Leicester Royal Infirmary, Leicester, UK.
J
J
Hunter
Department of Vascular Surgery at Leicester Royal Infirmary, Leicester, UK.
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V
Cairns
Department of Vascular Surgery at Leicester Royal Infirmary, Leicester, UK.
R
R
Sandford
Department of Vascular Surgery at Leicester Royal Infirmary, Leicester, UK.
A
A
Munshi
Department of Vascular Surgery at Leicester Royal Infirmary, Leicester, UK. Electronic address: ross.naylor@uhl-tr.nhs.uk.
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AR
Naylor
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001241:Aspirin / Q000008:administration & dosage* / Q000009:adverse effects; D016063:Blood Loss, Surgical / Q000517:prevention & control; D016893:Carotid Stenosis / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D000077144:Clopidogrel; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D016894:Endarterectomy, Carotid / Q000009:adverse effects; D004739:England; D005260:Female; D006801:Humans; D002546:Ischemic Attack, Transient / Q000175:diagnosis / Q000453:epidemiology / Q000517:prevention & control*; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D016017:Odds Ratio; D010360:Patient Transfer; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects; D019106:Postoperative Hemorrhage / Q000139:chemically induced / Q000453:epidemiology / Q000517:prevention & control; D015995:Prevalence; D011446:Prospective Studies; D012008:Recurrence; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013988:Ticlopidine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome
D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin
Carotid artery disease; Carotid endarterectomy; Medical therapy; Stroke