DiLosa Kathryn, Wolinsky Rachel, Harding Joel, Patibandla Anjani, Maximus Steven, MacCallum Katherine, Siada Sammy, Kwong Mimmie
Department of Surgery, University of California, Davis Health, Sacramento, CA.
UCSF Fresno, Division of Vascular Surgery, Fresno, CA.
Ann Vasc Surg. 2025 Jan;110(Pt A):226-232. doi: 10.1016/j.avsg.2024.09.031. Epub 2024 Sep 26.
Clopidogrel resistance testing is not routine prior to transcarotid artery revascularization (TCAR) and resistance rates are not well described in this setting despite frequent use of periprocedural clopidogrel. We compared 2 resistance testing modalities to determine the relationship between resistance and stent outcomes.
Consecutive patients undergoing TCAR at 3 institutions were retrospectively identified. Clopidogrel-resistance testing results and outcomes were described.
A total of 210 patients underwent TCAR from 2018-2022. One hundred fifty four (73%) were on dual antiplatelet therapy (DAPT) for at least 7 days prior to TCAR. Twenty-nine patients were not on DAPT due to therapeutic anticoagulation and most (38/56, 68%) received a loading dose of a second antiplatelet the day of surgery. Twenty-five patients (11.9%) experienced stent thrombosis within 30 days. Patients not on DAPT for at least 7 days prior to surgery were more prone to stent thrombosis (16.7% vs. 10.4%, P = 0.164). More than half (133/210, 63%) of patients underwent resistance testing, 25 with thromboelastography with platelet mapping (TEG-PM), 103 with VerifyNow P2Y12 platelet reactivity assay, and 5 with both. Prevalence of Clopidogrel resistance among tested patients was 41%. In patients tested using both TEG-PM and VerifyNow, agreement was poor (Cohen's Kappa -0.05). Among patients with resistance, 12 (22%) experienced stent thrombosis. Comparatively, 8 (10%) patients without resistance developed thrombosis (P = 0.021). VerifyNow P2Y12 platelet reactivity assay correctly predicted Clopidogrel resistance more accurately than TEG-PM (70% vs. 40%, P = 0.025) and had sensitivity of 56% and specificity of 73% for stent thrombosis.
Our multi-institutional cohort confirms a high rate of Clopidogrel resistance in patients undergoing TCAR, with higher acute stent thrombosis rates noted in patients with resistance. VerifyNow P2Y12 platelet reactivity assays more reliably predict Clopidogrel resistance than TEG-PM.
在经颈动脉血管重建术（TCAR）之前，氯吡格雷抵抗检测并非常规操作，尽管围手术期经常使用氯吡格雷，但在这种情况下抵抗率尚未得到充分描述。我们比较了两种抵抗检测方式，以确定抵抗与支架置入结果之间的关系。
对3家机构连续接受TCAR的患者进行回顾性识别。描述氯吡格雷抵抗检测结果和结局。
2018年至2022年共有210例患者接受了TCAR。154例（73%）在TCAR前至少7天接受双联抗血小板治疗（DAPT）。29例患者因治疗性抗凝未接受DAPT，大多数（38/56，68%）在手术当天接受了第二剂抗血小板药物的负荷剂量。25例患者（11.9%）在30天内发生支架血栓形成。术前未接受至少7天DAPT的患者更容易发生支架血栓形成（16.7%对10.4%，P = 0.164）。超过一半（133/210，63%）的患者接受了抵抗检测，25例采用血栓弹力图血小板功能分析（TEG-PM），103例采用VerifyNow P2Y12血小板反应性检测，5例同时采用两种检测。检测患者中氯吡格雷抵抗的患病率为41%。在同时使用TEG-PM和VerifyNow检测的患者中，一致性较差（Cohen's Kappa -0.05）。在有抵抗的患者中，12例（22%）发生了支架血栓形成。相比之下，8例（10%）无抵抗的患者发生了血栓形成（P = 0.021）。VerifyNow P2Y12血小板反应性检测比TEG-PM更准确地预测氯吡格雷抵抗（70%对40%，P = 0.025），对支架血栓形成的敏感性为56%，特异性为73%。
我们的多机构队列证实，接受TCAR的患者中氯吡格雷抵抗率较高，有抵抗的患者急性支架血栓形成率更高。VerifyNow P2Y12血小板反应性检测比TEG-PM更可靠地预测氯吡格雷抵抗。
