Department of Neurosurgery, Nara Medical University, Nara, Japan.
Department of Radiology, Nara Medical University, Nara, Japan.
J Vasc Surg. 2014 Mar;59(3):761-7. doi: 10.1016/j.jvs.2013.09.011. Epub 2013 Nov 14.
Optimal platelet inhibition is an important therapeutic adjunct in patients with carotid artery stenosis undergoing carotid artery stenting (CAS). Clopidogrel resistance is associated with increased periprocedural thromboembolic complications from neurovascular stent placement procedures. The addition of cilostazol to dual antiplatelet therapy (DAT) has been reported to reduce platelet reactivity and to improve clinical outcomes after percutaneous coronary intervention. This study was undertaken to evaluate the impact of adjunctive cilostazol in patients with CAS.
Platelet function was assessed by light transmittance aggregometry using the VerifyNow assay. Sixty-four consecutive patients who underwent CAS received standard DAT, clopidogrel (75 mg daily), and aspirin (100 mg daily) more than 4 weeks before the procedure. From 2010 to 2011 (period I), 28 patients underwent CAS under standard DAT. From 2011 to 2013 (period II), 36 patients prospectively had preoperative assessment of platelet function, and 13 patients with clopidogrel resistance received adjunctive cilostazol (200 mg daily) in addition to standard DAT. The incidence of new ipsilateral ischemic lesions on diffusion-weighted imaging a day after CAS and ischemic or hemorrhagic events within 30 days was assessed.
Clopidogrel resistance was indentified in 12 patients (43%) in period I and 13 patients (36%) in period II (P = .615). In period II, the addition of cilostazol significantly decreased P2Y12 reaction units and % inhibition (P = .006 and P = .005, respectively), and there was a significant difference in P2Y12 reaction units between the two periods. New ipsilateral ischemic lesions were significantly decreased in period II (2/36 patients) compared with period I (7/28 patients; P = .034); however, there was no significant difference in hemorrhagic and thromboembolic events between the two periods.
Adjunctive cilostazol (triple antiplatelet therapy) in clopidogrel-resistant patients reduces the rate of clopidogrel resistance and suppresses new ischemic lesions without hemorrhagic complications, as compared with standard DAT. Antiplatelet management based on the evaluation of antiplatelet resistance would be required for prevention of perioperative thromboembolic complications in CAS.
在接受颈动脉支架置入术（CAS）的颈动脉狭窄患者中，最佳血小板抑制是一种重要的治疗辅助手段。氯吡格雷抵抗与神经血管支架置入术的围手术期血栓栓塞并发症增加有关。加用西洛他唑双联抗血小板治疗（DAT）已被报道可降低血小板反应性，并改善经皮冠状动脉介入治疗后的临床结局。本研究旨在评估辅助西洛他唑在 CAS 患者中的影响。
通过使用 VerifyNow 检测血小板功能通过光透射聚集测定进行评估。64 例连续接受 CAS 的患者在术前 4 周以上接受标准 DAT、氯吡格雷（每日 75mg）和阿司匹林（每日 100mg）治疗。2010 年至 2011 年（第一期），28 例患者接受标准 DAT 下的 CAS。2011 年至 2013 年（第二期），36 例患者前瞻性评估血小板功能，13 例氯吡格雷抵抗患者在标准 DAT 基础上加用辅助西洛他唑（每日 200mg）。评估 CAS 后第 1 天扩散加权成像上新同侧缺血性病变的发生率和 30 天内缺血或出血事件的发生率。
第一期有 12 例（43%）患者存在氯吡格雷抵抗，第二期有 13 例（36%）患者存在氯吡格雷抵抗（P=0.615）。第二期加用西洛他唑可显著降低 P2Y12 反应单位和%抑制率（P=0.006 和 P=0.005），且两期之间 P2Y12 反应单位存在显著差异。第二期新同侧缺血性病变较第一期明显减少（2/36 例比 7/28 例；P=0.034）；然而，两期之间出血和血栓栓塞事件无显著差异。
与标准 DAT 相比，氯吡格雷抵抗患者加用西洛他唑（三联抗血小板治疗）可降低氯吡格雷抵抗率，抑制新的缺血性病变，且无出血并发症。基于抗血小板反应性评估的抗血小板管理可能有助于预防 CAS 围手术期血栓栓塞并发症。
