Long-term antithrombotic therapy after carotid endarterectomy for symptomatic carotid disease: an international survey of practice patterns, guideline concordance and trial readiness for dual pathway inhibition.

OBJECTIVES: Long-term antithrombotic therapy after carotid endarterectomy (CEA) for symptomatic carotid disease reduces recurrent vascular events, but the preferred regimen varies across regions and the role of intensified strategies remains uncertain. We aimed to describe current international post-CEA antithrombotic practice, assess concordance with regional guidance, and examine willingness to adopt or formally evaluate dual pathway inhibition based on the COMPASS regimen. METHODS: We conducted an international electronic survey of practising vascular surgeons who perform CEA. Respondents were asked about their routine long-term antithrombotic regimen after CEA for symptomatic carotid disease in patients without atrial fibrillation, their attitudes to low-dose rivaroxaban plus aspirin in routine practice and within a randomised trial, perceived barriers to adoption, and estimated annual recruitment capacity. Guideline concordance was assessed using prespecified regional rules. RESULTS: A total of 356 vascular surgeons responded, including 191 from the United Kingdom, 107 from Europe, 35 from Australasia and 23 from Brazil. Clopidogrel monotherapy was the most commonly reported regimen (55%), followed by aspirin monotherapy (30%), dual antiplatelet therapy (11%), and low-dose rivaroxaban plus aspirin (4%). Using the primary concordance definition, 66.6% of responses aligned with regional guidance and 33.4% were discordant. Routine adoption of the COMPASS regimen was supported by 42% of respondents, whereas 67.5% supported evaluation within a randomised trial. The most frequently cited barrier was the absence of CEA-specific evidence (54%), followed by bleeding concerns (18%). Sixty-five per cent of centres estimated that they could recruit more than ten patients annually into a relevant trial. CONCLUSIONS: Reported long-term antithrombotic practice after CEA for symptomatic carotid disease varies internationally and often diverges from regional guidance. Surgeons appear more willing to evaluate dual pathway inhibition in a trial than to adopt it routinely, suggesting substantial clinical equipoise. Future work should define the optimal post-CEA regimen using procedure-specific evidence.