Periprocedural P2Y₁₂ inhibitors improve perioperative outcomes after carotid stenting by primarily decreasing strokes

Objective: The continuation of antiplatelet agents in the periprocedural period around carotid stenting (CAS) procedures is felt to be mandatory to minimize the risk of periprocedural stroke. However, the optimal antiplatelet regimen is unclear, with some advocating dual antiplatelet therapy, and others supporting the use of P2Y₁₂ inhibitors alone. The objective of this study was to evaluate the periprocedural effect of P2Y₁₂ inhibitors for CAS. Methods: The Vascular Quality Initiative was used from years 2007 to 2020. All transcarotid artery revascularization (TCAR) and transfemoral carotid artery stenting (TF-CAS) procedures were included. Patients were stratified based on perioperative use of P2Y₁₂ inhibitors as well as symptomatic status. Primary end points were perioperative neurological events (strokes and transient ischemic attacks). Secondary end points were mortality and myocardial infarction. Results: A total of 31,036 CAS procedures were included for analysis, with 49.8% TCAR and 50.2% TF-CAS cases; 63.8% of patients were male and 82.3% of patients were on a P2Y₁₂ inhibitor. P2Y₁₂ inhibitor use was more common in males, asymptomatic patients, those older than 70 years, and concurrent statin use. P2Y₁₂ inhibitors were more likely to be used in TCAR cases than in TF-CAS cases (87.3% vs 76.8%; P <.001). The rate of periprocedural neurological events in the whole cohort was 2.6%. Patients on P2Y₁₂ inhibitors were significantly less likely to experience a periprocedural neurological event (2.3% vs 3.9%; P <.001) and mortality (0.6% vs 2.1%; P <.001) than those who were not on a P2Y₁₂ inhibitor. There was no effect on the rates of myocardial infarction. On multivariate analysis, both symptomatic and asymptomatic patients on P2Y₁₂ inhibitors were significantly less likely to develop perioperative neurological events. Additionally, the use of P2Y₁₂ inhibitors demonstrated an independent significant effect in reducing of the rate of perioperative stroke (odds ratio, 0.29; 95% confidence interval, 0.25-0.33). Finally, additional analysis of the types of P2Y₁₂ inhibitors used revealed that all seemed to be equally effective in decreasing the periprocedural neurological event rate. Conclusions: The use of perioperative P2Y₁₂ inhibitors seems to markedly decrease the perioperative neurological event rate with TCAR and TF-CAS in both symptomatic and asymptomatic patients and should be strongly considered. Patients with contraindications to P2Y₁₂ inhibitors may not be appropriate candidates for any CAS procedure. Additionally, alternative types of P2Y₁₂ inhibitors seem to be equally effective as clopidogrel. Finally, an analysis of the Vascular Quality Initiative demonstrates that, even for TCAR cases, only 87.3% of patients seem to be on P2Y₁₂ inhibitors in the periprocedural period, leaving room for significant improvement.