Jones Douglas W, Goodney Philip P, Conrad Mark F, Nolan Brian W, Rzucidlo Eva M, Powell Richard J, Cronenwett Jack L, Stone David H
Department of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH.
J Vasc Surg. 2016 May;63(5):1262-1270.e3. doi: 10.1016/j.jvs.2015.12.020. Epub 2016 Mar 2.
Controversy persists regarding the perioperative management of clopidogrel among patients undergoing carotid endarterectomy (CEA). This study examined the effect of preoperative dual antiplatelet therapy (aspirin and clopidogrel) on in-hospital CEA outcomes.
Patients undergoing CEA in the Vascular Quality Initiative were analyzed (2003-2014). Patients on clopidogrel and aspirin (dual therapy) were compared with patients taking aspirin alone preoperatively. Study outcomes included reoperation for bleeding and thrombotic complications defined as transient ischemic attack (TIA), stroke, or myocardial infarction. Secondary outcomes were in-hospital death and composite stroke/death. Univariate and multivariable analyses assessed differences in demographics and operative factors. Propensity score-matched cohorts were derived to control for subgroup heterogeneity.
Of 28,683 CEAs, 21,624 patients (75%) were on aspirin and 7059 (25%) were on dual therapy. Patients on dual therapy were more likely to have multiple comorbidities, including coronary artery disease (P < .001), congestive heart failure (P < .001), and diabetes (P < .001). Patients on dual therapy were also more likely to have a drain placed (P < .001) and receive protamine during CEA (P < .001). Multivariable analysis showed that dual therapy was independently associated with increased reoperation for bleeding (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.20-2.42; P = .003) but was protective against TIA or stroke (OR, 0.61; 95% CI, 0.43-0.87; P = .007), stroke (OR, 0.63; 95% CI, 0.41-0.97; P = .03), and stroke/death (OR, 0.66; 95% CI, 0.44-0.98; P = .04). Propensity score matching yielded two groups of 4548 patients and showed that patients on dual therapy were more likely to require reoperation for bleeding (1.3% vs 0.7%; P = .004) but less likely to suffer TIA or stroke (0.9% vs 1.6%; P = .002), stroke (0.6% vs 1.0%; P = .04), or stroke/death (0.7% vs 1.2%; P = .03). Within the propensity score-matched groups, patients on dual therapy had increased rates of reoperation for bleeding regardless of carotid symptom status. However, asymptomatic patients on dual therapy demonstrated reduced rates of TIA or stroke (0.6% vs 1.5%; P < .001), stroke (0.4% vs 0.9%; P = .01), and composite stroke/death (0.5% vs 1.0%; P = .02). Among propensity score-matched patients with symptomatic carotid disease, these differences were not statistically significant.
Preoperative dual antiplatelet therapy was associated with a 40% risk reduction for neurologic events but also incurred a significant increased risk of reoperation for bleeding after CEA. Given its observed overall neurologic protective effect, continued dual antiplatelet therapy throughout the perioperative period is justified. Initiating dual therapy in all patients undergoing CEA may lead to decreased neurologic complication rates.
对于接受颈动脉内膜切除术（CEA）的患者，围手术期氯吡格雷的管理仍存在争议。本研究探讨术前双联抗血小板治疗（阿司匹林和氯吡格雷）对CEA院内结局的影响。
分析血管质量改进计划中接受CEA的患者（2003 - 2014年）。将服用氯吡格雷和阿司匹林（双联治疗）的患者与术前仅服用阿司匹林的患者进行比较。研究结局包括因出血和血栓形成并发症进行再次手术，血栓形成并发症定义为短暂性脑缺血发作（TIA）、卒中或心肌梗死。次要结局为院内死亡和卒中/死亡复合结局。单因素和多因素分析评估人口统计学和手术因素的差异。采用倾向评分匹配队列以控制亚组异质性。
在28,683例CEA手术中，21,624例患者（75%）服用阿司匹林，7059例患者（25%）接受双联治疗。接受双联治疗的患者更可能有多种合并症，包括冠状动脉疾病（P <.001）、充血性心力衰竭（P <.001）和糖尿病（P <.001）。接受双联治疗的患者也更可能放置引流管（P <.001）并在CEA手术期间接受鱼精蛋白（P <.001）。多因素分析显示，双联治疗与出血后再次手术增加独立相关（比值比[OR]，1.71；95%置信区间[CI]，1.20 - 2.42；P =.003），但对TIA或卒中具有保护作用（OR，0.61；95% CI，0.43 - 0.87；P =.007）、卒中（OR，0.63；
