Carotid Endarterectomy on Antiplatelet Agents in the Era of Point-of-Care Testing

Impact of Continued Clopidogrel use on Outcomes of Patients undergoing Carotid Endarterectomy

OBJECTIVES

To evaluate the use of clopidogrel at the time of carotid endarterectomy (CEA) and its association with postoperative complications.

METHODS

Single institution, retrospective review of a prospective database.

RESULTS

From 2010 to 2017, CEA was performed in 1066 consecutive patients (median age 73 years, 66% men). The indications for operation included ≥70% asymptomatic stenosis (458, 43%), prior stroke (314, 29%), and transient cerebral or retinal ischemia (294, 28%). At the time of operation, 509 (48%) patients were taking aspirin alone, 441 (41%) were taking clopidogrel (374 in combination with aspirin, 67 as sole therapy), 83 (8%) were on no documented antiplatelet medication, and 33 (3%) were taking warfarin (with therapeutic INR). The likelihood of clopidogrel use at the time of operation was higher for patients with a history of symptomatic carotid disease (p=0.002). Over the study period, clopidogrel use increased from 31.9% in 2010 to, 56.8% in 2017 that corresponds to 11% 95%CI (6, 15) increase annually. Postoperative strokes occurred in 15 patients (overall incidence 1.4%), the majority of which were minor (12/15, 80%). Six strokes occurred in patients taking aspirin alone (6/509, 1.2%), 2 in patients on clopidogrel and aspirin (2/441, 0.5%), 2 in patients taking clopidogrel alone (2/67, 2.9%), 3 in patients on no documented antiplatelet medication (3/83, 3.6%), and 2 in those taking warfarin (one of which was secondary to a fatal intracranial hemorrhage within 30 d of discharge; 2/33, 6.1%). The 30-day mortality rate was 0.03% (3/1066); the risk for the combined endpoint of any stroke, death or myocardial infarction (MI) was 2.3% (25/1066), and the risk for major stroke, death, or MI was 1.2%. There was no apparent association between clopidogrel use and the incidence of postoperative bleeding (p=0.59) or any other postoperative complication (stroke, death, MI, cranial nerve injury, p=0.15).

CONCLUSIONS

Clopidogrel use in our CEA practice has increased over time and has not been associated with an increased risk of postoperative complications, including bleeding. These data suggest that clopidogrel should not be discontinued prior to CEA, and should be considered as part of 'optimal medical therapy' in patients undergoing CEA.

Patient Blood Management in Vascular Surgery

Patient blood management (PBM) is an evidence-based, multidisciplinary approach aimed at appropriately allocating blood products to patients requiring transfusion while simultaneously minimizing inappropriate transfusions. The 3 pillars of patient blood management are optimizing erythropoiesis, minimizing blood loss, and optimizing physiological reserve of anemia. Benefits seen from PBM include limiting hospital costs and mitigating harm from numerous risks of transfusion.

Progressive hemiparesis due to spino-laminar anomaly of the axis-a case report and literature review

Introduction

Some of the most common developmental malformations of the axis include anomalies of the odontoid, for example, hypoplasia or aplasia. Isolated anomalies of the posterior arch of the axis rarely occur. This study reports a unique case of congenital anomaly of the neural arch of the axis vertebra, which manifested clinically as progressive hemiparesis.

Case presentation

A 33-year-old man presented with progressive weakness of the right upper and lower limbs that had lasted 18 months. The patient reported loss of right-hand dexterity in the 6 months period before he consulted us. Plain radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) revealed C5-C6 block vertebra, primary canal stenosis and spino-laminar anomaly of the axis, along with invagination of the lamina into the canal causing severe cord compression.

Discussion

The anomalous posterior element of the axis was excised, and the cord was decompressed. The presence of congenital stenosis and block vertebrae at the C5-C6 level necessitated decompression and instrumentation between C2-C6. Simultaneous occurrence of a posterior arch anomaly, primary canal stenosis, and block vertebra has not been previously described. A cervical spine anomaly presenting as hemiparesis is uncommon in clinical practice. Information enabling clinicians to identify causative anomaly and determine the appropriate surgical intervention is useful, and can facilitate a good clinical outcome.

Carotid Endarterectomy and Concurrent Clopidogrel Use: National Practice Patterns in the United States

BACKGROUND

Patients with diagnoses of high-grade carotid stenosis are often placed on antiplatelet therapy and undergo carotid endarterectomy (CEA) during their hospital stay. There is intersurgeon variability in offering CEA to patients specifically on the potent antiplatelet agent clopidogrel.

METHODS

Utilizing the Premier database, data from adults with principal discharge diagnosis of stroke, transient ischemic attack (TIA), or carotid artery stenosis or occlusion without stroke/TIA (CAS) who had a CEA during the same hospital stay in 2014 were analyzed. Recent clopidogrel or aspirin use was defined as within 3 days before CEA. Univariate and multivariate analyses were used to examine the association of age, race, gender, symptomatic versus asymptomatic carotid stenosis, academic versus non-academic center, and regions of the United States with recent antiplatelet use before CEA.

RESULTS

There were 15,381 patients (median age, 71 years, interquartile range 65-78; 42% females) with stroke, TIA, or CAS who had a CEA during the same hospital stay in 2014 within the Premier databse. Of these, 2570 patients (16.7%) received clopidogrel, 4992 (32.5%) received aspirin but no clopidogrel, and 7819 (50.8%) received no clopidogrel/aspirin immediately before CEA. Younger patient age, treatment at a non-academic center, symptomatic carotid stenosis, and being in the Northeast or South were associated higher odds of being on clopidogrel therapy prior to CEA.

CONCLUSIONS

Across the United States, 1 in 6 patients was on clopidogrel therapy prior to undergoing a CEA. Patients with symptomatic carotid stenosis were most likely to be on clopidogrel therapy prior to their CEA. Future systematic analysis of differences in outcomes and safety events are needed.