Clopidogrel versus ticagrelor for antiplatelet therapy in transcarotid artery revascularization in the Society for Vascular Surgery Vascular Quality Initiative

Transcarotid artery revascularization (TCAR) with dynamic flow reversal is a hybrid technique for operative management of carotid artery stenosis. Dual antiplatelet therapy is recommended for patients undergoing TCAR; however, nonresponders to these medications may be predisposed to perioperative thromboembolic complications. Prevalent in up to 44% to 66% of patients taking clopidogrel, high on-treatment platelet reactivity may thus be responsible for a portion of adverse cerebrovascular events in TCAR. A previous single-institution study has demonstrated the use of ticagrelor as a viable alternative to clopidogrel for antiplatelet therapy in patients undergoing TCAR; however, large-scale comparisons between clopidogrel and ticagrelor are needed to confirm the safety of ticagrelor outside of highly selected patients and providers.Data from patients enrolled in the Society for Vascular Surgery Vascular Quality Initiative undergoing TCAR with a perioperative antiplatelet therapy regimen including either clopidogrel or ticagrelor from January 2015 to March 2021 were analyzed and compared. Multivariable logistic regression and propensity score matching were used to evaluate the primary 30-day outcomes of stroke, major bleeding event, and combined stroke/myocardial infarction (MI)/death rate while adjusting for baseline characteristics of the patients.A total of 11,973 patients underwent TCAR with a dual antiplatelet therapy regimen that included clopidogrel vs 426 patients with ticagrelor. Compared with patients on clopidogrel, patients on ticagrelor were significantly more likely to have coronary artery disease (51% vs 66%; P < .001), particularly unstable angina or MI within 6 months (3% vs 9%; P < .001), and more likely to have insulin-dependent diabetes mellitus (14% vs 19%; P < .001). The unadjusted 30-day rates of stroke, major bleeding, and combined stroke/MI/death were not statistically significant among both groups (1.3% vs 0.5%; P = .14, 2.4% vs 1.4%; P = .18, and 1.9% vs 1.6%; P = .71], respectively). After multivariable adjustment and propensity matching, these remained statistically insignificant.Despite a substantially higher medical risk in patients undergoing TCAR with ticagrelor, 30-day rates of stroke, major bleeding events, and combined stroke/MI/death were similar between patients on ticagrelor and clopidogrel as part of adjunctive antiplatelet therapy. Randomized prospective trials, and studies with larger sample sizes and longer follow-up will be needed to better examine the outcome differences in TCAR between these two medications.