Perioperative antiplatelet therapy for carotid endarterectomy: a systematic review and meta-analysis_West China Medical Journal

Authors：

TANG Qin , GUO Yijia , HU Renzhong , TANG Yifang , WANG Xiaoqing , ZHANG Yujiao , LIN Yapeng , HAO Junli ,  YANG Jie

Department of Neurology, the First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, P. R. China;

Corresponding?author：

YANG Jie, Email: yangjie1126@163.com

Keywords：

Carotid endarterectomy; Antiplatelet treatment; Meta-analysis

DOI：

10.7507/1002-0179.202004487

Video：

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Objective To evaluate the efficacy and safety of perioperative dual antiplatelet treatment (DAPT) or single antiplatelet treatment (SAPT) for patients undergoing carotid endarterectomy (CEA).Methods We searched English and Chinese databases, including PubMed, Embase, Cochrane, Web of Science, Chinese National Knowledge Infrastructure, Wanfang database, Chongqing VIP, and relevant clinical trial registry platforms (searched from database establishment to January 2020). Cohort studies or randomized controlled trials (RCTs) were included to evaluated the use of DAPT and SAPT for patients undergoing CEA. Stroke, myocardial infarction, artery restenosis, and composite endpoint (stroke or myocardial infarction or artery restenosis) were used as effectiveness outcomes. Death and any bleeding event were used as safety outcomes. Meta-analysis was performed with Review Manager 5.3 and STATA 15.1 softwares.Results A total of 11 studies with 123 748 patients were included. The results of meta-analysis showed that there was no significant decrease in the risk of stroke [relative risk (RR)=0.82, 95% confidence interval (CI) (0.66, 1.01), P=0.06], myocardial infarction [RR=1.31, 95%CI (0.92, 1.87), P=0.13], artery restenosis [RR=0.55, 95%CI (0.18, 1.68), P=0.29], or composite endpoint event [RR=0.90, 95%CI (0.59, 1.37), P=0.62] for CEA patients with DAPT during the perioperative period compared with SAPT. The difference in mortality rate was not statistically significant between DAPT and SAPT for CEA patients during the perioperative period [RR=0.99, 95%CI (0.44, 2.22), P=0.97]. CEA patients with DAPT had a higher risk of any bleeding event [RR=1.64, 95%CI (1.08, 2.50), P=0.02].Conclusions Perioperative CEA patients with DAPT are not associated with a lower risk of vascular events recurrence, but the risk of any bleeding event may increase. Therefore, SAPT during the perioperative period of patients undergoing CEA may be better than DAPT.

Citation： TANG Qin, GUO Yijia, HU Renzhong, TANG Yifang, WANG Xiaoqing, ZHANG Yujiao, LIN Yapeng, HAO Junli, YANG Jie. Perioperative antiplatelet therapy for carotid endarterectomy: a systematic review and meta-analysis. West China Medical Journal, 2020, 35(6): 664-672. doi: 10.7507/1002-0179.202004487 Copy

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14.	Saadeh C, Sfeir J. Discontinuation of preoperative clopidogrel is unnecessary in peripheral arterial surgery. J Vasc Surg, 2013, 58(6): 1586-1592.
15.	Chechik O, Goldstein Y, Behrbalk E, et al. Blood loss and complications following carotid endarterectomy in patients treated with clopidogrel. Vascular, 2012, 20(4): 193-197.
16.	Stone DH, Goodney PP, Schanzer A, et al. Clopidogrel is not associated with major bleeding complications during peripheral arterial surgery. J Vasc Surg, 2011, 54(3): 779-784.
17.	Payne D, Jones CI, Hayes PD, et al. Beneficial effects of clopidogrel combined with aspirin in reducing cerebral emboli in patients undergoing carotid endarterectomy. Circulation, 2004, 109(12): 1476-1481.
18.	Illuminati G, Schneider F, Pizzardi G, et al. Dual antiplatelet therapy does not increase the risk of bleeding after carotid endarterectomy: results of a prospective study. Ann Vasc Surg, 2017, 40: 39-43.
19.	溫神賜. 50例頸動脈內膜剝脫術的臨床分析. 福州: 福建醫科大學, 2018.
20.	Barboza M, Chang J, Hernández A, et al. Safety of dual antiplatelet therapy after carotid endarterectomy for prevention of restenosis: a single center experience. J Vasc Interv Neurol, 2016, 9(2): 5-9.
21.	Mangieri A, Gallo F, Sticchi A, et al. Dual antiplatelet therapy in coronary artery disease: from the past to the future prospective. Cardiovasc Interv Ther, 2020, 35(2): 117-129.
22.	中華醫學會心血管病學分會, 中華心血管病雜志編輯委員會. 急性ST段抬高型心肌梗死診斷和治療指南(2019). 中華心血管病雜志, 2019, 47(10): 766-783.

1. Jensen M, Thomalla G. Causes and secondary prevention of acute ischemic stroke in adults. Hamostaseologie, 2020, 40(1): 22-30.
2. GBD 2016 Neurology Collaborators. Global, regional, and national burden of neurological disorders, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol, 2019, 18(5): 459-480.
3. Brott TG, Howard G, Roubin GS, et al. Long-term results of stenting versus endarterectomy for carotid-artery stenosis. N Engl J Med, 2016, 374(11): 1021-1031.
4. Reznik M, Kamel H, Gialdini G, et al. Timing of carotid revascularization procedures after ischemic stroke. Stroke, 2017, 48(1): 225-228.
5. 陳忠, 楊耀國. 頸動脈狹窄診治指南. 中國血管外科雜志(電子版), 2017, 9(3): 169-175.
6. Liapis CD, Bell PF, Mikhailidis DP, et al. ESVS Guidelines: Section A--prevention in patients with carotid stenosis. Curr Vasc Pharmacol, 2010, 8(5): 673-681.
7. Jones DW, Goodney PP, Conrad MF, et al. Dual antiplatelet therapy reduces stroke but increases bleeding at the time of carotid endarterectomy. J Vasc Surg, 2016, 63(5): 1262-1270.
8. Hale B, Pan W, Misselbeck TS, et al. Combined clopidogrel and aspirin therapy in patients undergoing carotid endarterectomy is associated with an increased risk of postoperative bleeding. Vascular, 2013, 21(4): 197-204.
9. Oldag A, Schreiber S, Schreiber S, et al. Risk of wound hematoma at carotid endarterectomy under dual antiplatelet therapy. Langenbecks Arch Surg, 2012, 397(8): 1275-1282.
10. Zimmermann A, Knappich C, Tsantilas P, et al. Different perioperative antiplatelet therapies for patients treated with carotid endarterectomy in routine practice. J Vasc Surg, 2018, 68(6): 1753-1763.
11. Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials:is blinding necessary?. Control Clin Trials, 1996, 17(1): 1-12.
12. 鐘黛云. 基于Beers標準的老年人PIM相關結局和降糖藥物安全性系統評價. 廣州: 暨南大學, 2017.
13. 曾憲濤, 劉慧, 陳曦, 等. Meta分析系列之四: 觀察性研究的質量評價工具. 中國循證心血管醫學雜志, 2012, 4(4): 297-299.
14. Saadeh C, Sfeir J. Discontinuation of preoperative clopidogrel is unnecessary in peripheral arterial surgery. J Vasc Surg, 2013, 58(6): 1586-1592.
15. Chechik O, Goldstein Y, Behrbalk E, et al. Blood loss and complications following carotid endarterectomy in patients treated with clopidogrel. Vascular, 2012, 20(4): 193-197.
16. Stone DH, Goodney PP, Schanzer A, et al. Clopidogrel is not associated with major bleeding complications during peripheral arterial surgery. J Vasc Surg, 2011, 54(3): 779-784.
17. Payne D, Jones CI, Hayes PD, et al. Beneficial effects of clopidogrel combined with aspirin in reducing cerebral emboli in patients undergoing carotid endarterectomy. Circulation, 2004, 109(12): 1476-1481.
18. Illuminati G, Schneider F, Pizzardi G, et al. Dual antiplatelet therapy does not increase the risk of bleeding after carotid endarterectomy: results of a prospective study. Ann Vasc Surg, 2017, 40: 39-43.
19. 溫神賜. 50例頸動脈內膜剝脫術的臨床分析. 福州: 福建醫科大學, 2018.
20. Barboza M, Chang J, Hernández A, et al. Safety of dual antiplatelet therapy after carotid endarterectomy for prevention of restenosis: a single center experience. J Vasc Interv Neurol, 2016, 9(2): 5-9.
21. Mangieri A, Gallo F, Sticchi A, et al. Dual antiplatelet therapy in coronary artery disease: from the past to the future prospective. Cardiovasc Interv Ther, 2020, 35(2): 117-129.
22. 中華醫學會心血管病學分會, 中華心血管病雜志編輯委員會. 急性ST段抬高型心肌梗死診斷和治療指南(2019). 中華心血管病雜志, 2019, 47(10): 766-783.

West China Medical Journal

Perioperative antiplatelet therapy for carotid endarterectomy: a systematic review and meta-analysis

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