Antithrombotic treatment and outcome after endovascular treatment and acute carotid artery stenting in stroke patients with atrial fibrillation

Johannes M Weller, Franziska Dorn, Julius N Meissner, Sebastian Stösser, Niklas M Beckonert, Julia Nordsiek, Christine Kindler, Christoph Riegler, Fee Keil, Gabor C Petzold, Felix J Bode, GSR-ET investigators, A Reich, O Nikoubashman, J Röther, B Eckert, M Braun, G F Hamann, E Siebert, C H Nolte, G Bohner, R M Eckert, J Borggrefe, P Schellinger, J Berrouschot, A Bormann, C Kraemer, H Leischner, M Petersen, F Stögbauer, T Boeck-Behrens, S Wunderlich, A Ludolph, K H Henn, C Gerloff, J Fiehler, G Thomalla, A Alegiani, J H Schäfer, S Tiedt, L Kellert, C Trumm, U Ernemann, S Poli, J Liman, M Ernst, K Gröschel, T Uphaus, Johannes M Weller, Franziska Dorn, Julius N Meissner, Sebastian Stösser, Niklas M Beckonert, Julia Nordsiek, Christine Kindler, Christoph Riegler, Fee Keil, Gabor C Petzold, Felix J Bode, GSR-ET investigators, A Reich, O Nikoubashman, J Röther, B Eckert, M Braun, G F Hamann, E Siebert, C H Nolte, G Bohner, R M Eckert, J Borggrefe, P Schellinger, J Berrouschot, A Bormann, C Kraemer, H Leischner, M Petersen, F Stögbauer, T Boeck-Behrens, S Wunderlich, A Ludolph, K H Henn, C Gerloff, J Fiehler, G Thomalla, A Alegiani, J H Schäfer, S Tiedt, L Kellert, C Trumm, U Ernemann, S Poli, J Liman, M Ernst, K Gröschel, T Uphaus

Abstract

Background: Oral anticoagulation (OAC) is the mainstay of secondary prevention in ischemic stroke patients with atrial fibrillation (AF). However, in AF patients with large vessel occlusion stroke treated by endovascular therapy (ET) and acute carotid artery stenting (CAS), the optimal antithrombotic medication remains unclear.

Methods: This is a subgroup analysis of the German Stroke Registry-Endovascular Treatment (GSR-ET), a prospective multicenter cohort of patients with large vessel occlusion stroke undergoing ET. Patients with AF and CAS during ET were included. We analyzed baseline and periprocedural characteristics, antithrombotic strategies and functional outcome at 90 days.

Results: Among 6635 patients in the registry, a total of 82 patients (1.2%, age 77.9 ± 8.0 years, 39% female) with AF and extracranial CAS during ET were included. Antithrombotic medication at admission, during ET, postprocedural and at discharge was highly variable and overall mortality in hospital (21%) and at 90 days (39%) was high. Among discharged patients (n = 65), most frequent antithrombotic regimes were dual antiplatelet therapy (DAPT, 37%), single APT + OAC (25%) and DAPT + OAC (20%). Comparing DAPT to single or dual APT + OAC, clinical characteristics at discharge were similar (median NIHSS 7.5 [interquartile range, 3-10.5] vs 7 [4-11], p = 0.73, mRS 4 [IQR 3-4] vs. 4 [IQR 3-5], p = 0.79), but 90-day mortality was higher without OAC (32 vs 4%, p = 0.02).

Conclusions: In AF patients who underwent ET and CAS, 90-day mortality was higher in patients not receiving OAC.

Registration: https://www.

Clinicaltrials: gov ; Unique identifier: NCT03356392.

Keywords: Antiplatelet therapy; Carotid artery stenting; Clinical outcome; Endovascular treatment; Large vessel occlusion; Mechanical thrombectomy; Oral anticoagulation; Stroke.

Conflict of interest statement

JMW, JNM, SS, NMB, JN, CH, CB, FK, GCP, and FJB report no competing interests. FD received research funding from Cerenovus, speakers honorary from Cerenovus and Acandis and serves as a proctor and consultant for Cerus Endovascular, Balt and Cerenovus.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Antithrombotic medication and outcome at 90-day follow-up. A Sankey diagram of antithrombotic medication upon baseline, periprocedural, postprocedural and at discharge. B Functional outcome of stroke patients with atrial fibrillation after endovascular treatment and carotid artery stenting at 90-day follow-up (n = 82). C Comparison of functional outcome for patients discharged with dual antiplatelet therapy (n = 24) compared to patients with oral anticoagulation in addition to antiplatelet therapy (n = 29), see respective groups at ‘discharge’ in Panel A. Abbreviations: APT, antiplatelet therapy; DAPT, dual antiplatelet therapy; OAC, oral anticoagulation, HEP, therapeutic dosing of heparin; uk, unknown

References

    1. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American heart association/American stroke association. Stroke. 2018 doi: 10.1161/STR.0000000000000158.
    1. McKevitt FM, Randall MS, Cleveland TJ, Gaines PA, Tan KT, Venables GS. The benefits of combined anti-platelet treatment in carotid artery stenting. European Journal of Vascular and Endovascular Surgery. 2005;29:522–527. doi: 10.1016/j.ejvs.2005.01.012.
    1. Dalainas I, Nano G, Bianchi P, Stegher S, Malacrida G, Tealdi DG. Dual antiplatelet regime versus acetyl-acetic acid for carotid artery stenting. Cardiovascular and Interventional Radiology. 2006;29:519–521. doi: 10.1007/s00270-005-5288-y.
    1. Brott TG, Hobson RW, Howard G, Roubin GS, Clark WM, Brooks W, Mackey A, Hill MD, Leimgruber PP, Sheffet AJ, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. New England Journal of Medicine. 2010;363:11–23. doi: 10.1056/NEJMoa0912321.
    1. Eckstein H-H, Kühnl A, Berkefeld J, Lawall H, Storck M, Sander D. Diagnosis, treatment and follow-up in extracranial carotid stenosis. Deutsches Ärzteblatt International. 2020;117:801–807.
    1. Brown DL, Levine DA, Albright K, Kapral MK, Leung LY, Reeves MJ, Sico J, Strong B, Whiteley WN, on behalf of the American Heart Association Stroke Council Benefits and risks of dual versus single antiplatelet therapy for secondary stroke prevention: a systematic review for the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke. 2021 doi: 10.1161/STR.0000000000000377.
    1. Klijn CJ, Paciaroni M, Berge E, Korompoki E, Kõrv J, Lal A, Putaala J, Werring DJ. Antithrombotic treatment for secondary prevention of stroke and other thromboembolic events in patients with stroke or transient ischemic attack and non-valvular atrial fibrillation: A European Stroke Organisation guideline. European Stroke Journal. 2019;4:198–223. doi: 10.1177/2396987319841187.
    1. Alegiani AC, Dorn F, Herzberg M, Wollenweber FA, Kellert L, Siebert E, Nolte CH, von Rennenberg R, Hattingen E, Petzold GC, et al. Systematic evaluation of stroke thrombectomy in clinical practice: The German stroke registry endovascular treatment. International Journal of Stroke. 2019;14:372–380. doi: 10.1177/1747493018806199.
    1. Wollenweber FA, Tiedt S, Alegiani A, Alber B, Bangard C, Berrouschot J, Bode FJ, Boeckh-Behrens T, Bohner G, Bormann A, et al. Functional outcome following stroke thrombectomy in clinical practice. Stroke. 2019;50:2500–2506. doi: 10.1161/STROKEAHA.119.026005.
    1. ACTIVE Investigators Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. The Lancet. 2006;367:1903–1912. doi: 10.1016/S0140-6736(06)68845-4.
    1. Nii K, Takemura Y, Inoue R, Morinaga Y, Mitsutake T, Higashi T. Safety of direct oral anticoagulant—and antiplatelet therapy in patients with atrial fibrillation treated by carotid artery stenting. Journal of Stroke and Cerebrovascular Diseases. 2020;29:104899. doi: 10.1016/j.jstrokecerebrovasdis.2020.104899.
    1. Cohen JE, Gomori JM, Honig A, Leker RR. Carotid artery stenting in patients with atrial fibrillation: direct oral anticoagulants, brief double antiplatelets, and testing strategy. JCM. 2021;10:5242. doi: 10.3390/jcm10225242.
    1. Huang Y-C, Huang Y-C, Cheng Y-C, Chen M. Choice of antithrombotic therapy for patients with atrial fibrillation undergoing carotid angioplasty and stenting: A nationwide population-based study. Science and Reports. 2022;12:1417. doi: 10.1038/s41598-022-05546-8.
    1. Pardo-Galiana B, Medina-Rodriguez M, Millan-Vazquez M, Cabezas-Rodriguez JA, Lebrato-Hernandez L, Ainz-Gomez L, Zapata-Arriaza E, Ortega J, de Albóniga-Chindurza A, Montaner J, et al. Antithrombotic treatment after carotid stenting in patients with concomitant atrial fibrillation. AJNR American Journal of Neuroradiology. 2022;43:727–730. doi: 10.3174/ajnr.A7482.
    1. Aboyans V, Ricco J-B, Bartelink M-LEL, Björck M, Brodmann M, Cohnert T, Collet J-P, Czerny M, De Carlo M, Debus S, et al. ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European society for vascular surgery (ESVS) European Heart Journal. 2017;2018(39):763–816.
    1. Angiolillo DJ, Bhatt DL, Cannon CP, Eikelboom JW, Gibson CM, Goodman SG, Granger CB, Holmes DR, Lopes RD, Mehran R, et al. Antithrombotic therapy in patients with atrial fibrillation treated with oral anticoagulation undergoing percutaneous coronary intervention: A North American perspective: 2021 update. Circulation. 2021;143:583–596. doi: 10.1161/CIRCULATIONAHA.120.050438.
    1. Collet J-P, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European Heart Journal. 2021;42:1289–1367. doi: 10.1093/eurheartj/ehaa575.
    1. Khan SU, Osman M, Khan MU, Khan MS, Zhao D, Mamas MA, Savji N, Al-Abdouh A, Hasan RK, Michos ED. Dual versus triple therapy for atrial fibrillation after percutaneous coronary intervention: a systematic review and meta-analysis. Annals of Internal Medicine. 2020;172:474–483. doi: 10.7326/M19-3763.
    1. Kimura S, Toyoda K, Yoshimura S, Minematsu K, Yasaka M, Paciaroni M, Werring DJ, Yamagami H, Nagao T, Yoshimura S, et al. Practical “1–2–3–4-Day” rule for starting direct oral anticoagulants after ischemic stroke with atrial fibrillation: Combined hospital-based cohort study. Stroke. 2022 doi: 10.1161/STROKEAHA.121.036695.
    1. Seiffge DJ, Werring DJ, Paciaroni M, Dawson J, Warach S, Milling TJ, Engelter ST, Fischer U, Norrving B. Timing of anticoagulation after recent ischaemic stroke in patients with atrial fibrillation. The Lancet Neurology. 2019;18:117–126. doi: 10.1016/S1474-4422(18)30356-9.
    1. Cannon CP, Bhatt DL, Oldgren J, Lip GYH, Ellis SG, Kimura T, Maeng M, Merkely B, Zeymer U, Gropper S, et al. Dual antithrombotic therapy with dabigatran after PCI in atrial fibrillation. New England Journal of Medicine. 2017;377:1513–1524. doi: 10.1056/NEJMoa1708454.
    1. Gibson CM, Mehran R, Bode C, Halperin J, Verheugt FW, Wildgoose P, Birmingham M, Ianus J, Burton P, van Eickels M, et al. Prevention of bleeding in patients with atrial fibrillation undergoing PCI. New England Journal of Medicine. 2016;375:2423–2434. doi: 10.1056/NEJMoa1611594.
    1. Anadani M, Marnat G, Consoli A, Papanagiotou P, Nogueira RG, Siddiqui A, Ribo M, Spiotta AM, Bourcier R, Kyheng M, et al. Endovascular Therapy of anterior circulation tandem occlusions: pooled analysis from the TITAN and ETIS registries. Stroke. 2021;52:3097–3105. doi: 10.1161/STROKEAHA.120.033032.
    1. Jadhav AP, Zaidat OO, Liebeskind DS, Yavagal DR, Haussen DC, Hellinger FR, Jahan R, Jumaa MA, Szeder V, Nogueira RG, et al. Emergent management of tandem lesions in acute ischemic stroke. Stroke. 2019;50:428–433. doi: 10.1161/STROKEAHA.118.021893.
    1. Poppe AY, Stapf C, Raymond J. Letter by Poppe et al regarding article, emergent carotid stenting after thrombectomy in patients with tandem lesions. Stroke. 2017 doi: 10.1161/STROKEAHA.117.017837.
    1. Zhu F, Hossu G, Soudant M, Richard S, Achit H, Beguinet M, Costalat V, Arquizan C, Consoli A, Lapergue B, et al. Effect of emergent carotid stenting during endovascular therapy for acute anterior circulation stroke patients with tandem occlusion: A multicenter, randomized, clinical trial (TITAN) protocol. International Journal of Stroke. 2021;16:342–348. doi: 10.1177/1747493020929948.

Source: PubMed

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