Prince K Pekyi-Boateng, Christopher H Sollenberger, Georgios S Sioutas, Pierce H Davis, Arankesh Mahadevan, Albert Q Wu, Veronica Moreno-Gomez, Aaron Shoskes, Karol P Budohoski, Visish M Srinivasan, Ramesh Grandhi
Among patients undergoing CAS who required anticoagulation, DOAC combined with SAPT was associated with similar clinical outcomes compared with DOAC combined with DAPT. Given the theoretical hemorrhagic risk associated with triple antithrombotic therapy, these findings cautiously support consideration of DOAC + SAPT as a clinically reasonable alternative-particularly in patients at elevated bleeding risk-while recognizing that individual risk-benefit assessment remains essential. These data inform the design of a dedicated randomized controlled trial comparing antithrombotic regimens after CAS in patients requiring long-term anticoagulation.
BACKGROUND AND OBJECTIVES: The optimal antithrombotic therapy after carotid artery stenting (CAS) in patients requiring oral anticoagulation is uncertain; in particular, the safety and effectiveness of combining direct oral anticoagulants (DOACs) with single antiplatelet therapy (SAPT) compared with DOACs combined with dual antiplatelet therapy (DAPT) are not well-established.
METHODS: This retrospective cohort study used data from the TriNetX Research Network, which aggregates deidentified electronic health records from multiple healthcare organizations. Patients aged 35 to 90 years who underwent CAS between January 2010 and January 2025 were included. Patients receiving DOAC + SAPT were compared with those receiving DOAC + DAPT. Propensity score matching (1:1) was performed. The primary end point was intracranial hemorrhage, and secondary end points included gastrointestinal bleeding, all-cause mortality, venous thromboembolism, inpatient readmissions, new ischemic stroke, and head imaging utilization.
RESULTS: Of 1973 patients identified, 304 received DOAC + SAPT and 1669 received DOAC + DAPT before matching. After matching, 293 patients remained in each cohort. No statistically significant difference was observed between the 2 groups in the rate of intracranial hemorrhage (3.8% vs 4.1%, respectively; risk ratio 0.917, 95% CI, 0.411-2.044; P = .832). Other secondary outcomes like head imaging (P = .931), gastrointestinal bleeding (P = .456), all-cause mortality (P = .520), incidence of pulmonary embolism/deep venous thrombosis (P = .261), inpatient readmissions (P = .210), and new ischemic stroke (P = .101) were comparable between cohorts.
CONCLUSION: Among patients undergoing CAS who required anticoagulation, DOAC combined with SAPT was associated with similar clinical outcomes compared with DOAC combined with DAPT. Given the theoretical hemorrhagic risk associated with triple antithrombotic therapy, these findings cautiously support consideration of DOAC + SAPT as a clinically reasonable alternative-particularly in patients at elevated bleeding risk-while recognizing that individual risk-benefit assessment remains essential. These data inform the design of a dedicated randomized controlled trial comparing antithrombotic regimens after CAS in patients requiring long-term anticoagulation.