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  • Carotid Endarterectomy on Antiplatelet Agents in the Era of Point-of-care Testing

    Final Number:
    123

    Authors:
    Karam Moon MD; Michael Nanaszko MD; Bradley A Gross MD; Joseph M. Zabramski MD, FACS; Robert F. Spetzler MD; Peter Nakaji

    Study Design:
    Other

    Subject Category:
    Ischemic Stroke

    Meeting: AANS/CNS Cerebrovascular Section 2016 Annual Meeting

    Introduction:

    The safety of carotid endarterectomy in patients with a response to antiplatelet agents (aspirin and clopidogrel) confirmed by point-of-care testing is unknown. We set out to determine whether using point-of-care assessment of platelet inhibition reveals risk factors for operative complications or predicts clinical outcomes.

    Methods:

    We reviewed records of carotid endarterectomy patients from March 2013 to July 2015 for demographics, lesion characteristics, laboratory data, procedural complications, and follow-up. Administration of aspirin, clopidogrel, or therapeutic anticoagulation within 5 days before surgery was recorded.

    Results:

    We analyzed 79 patients with 86 lesions (mean age 70.9±10.0 years). More patients with a P2Y12 reaction unit (PRU) <170 had neck hematomas (4/10, 40.0%) compared with those with a PRU =170 (2/9, 22.2%), and more aspirin responders had neck hematomas (7/31, 22.6%) compared with non-aspirin responders (1/13, 7.7%); however, neither difference was statistically significant (Fisher’s exact rest, P=.63 and P=.40, respectively). Estimated blood loss (EBL) =100 mL was more frequent among patients with PRU <170 (9/10, 90.0%) than among those with PRU =170 (5/9, 55.6%) (P=.09). Clopidogrel use, regardless of response, independently predicted neck hematoma in a logistic regression model, with increased odds of 8.5. Mean postoperative modified Rankin Scale scores did not differ statistically between clopidogrel users and non-users at a mean follow-up of 108.5±146.3 days (P=.27).

    Conclusions:

    Clopidogrel use within 5 days of carotid endarterectomy independently predicted postoperative neck hematomas, most of which were managed conservatively. Patients with PRU <170 were more likely to have EBL =100 mL during surgery and surgery lasting =3 hours.

    Patient Care:

    Our data illustrate an important trend and the potential importance of point-of-care testing prior to carotid endarterectomy. We recommend that testing be performed in the preoperative work-up, and barring urgent settings or absolute contraindications to withholding preprocedural clopidogrel, more avid responders should perhaps be managed by withholding clopidogrel in the perioperative period.

    Learning Objectives:

    1. To discuss current literature regarding neurosurgical procedures in the setting of clopidogrel use. 2. To discuss current literature regarding carotid endarterectomy on antiplatelet therapy. 3. To discuss management of patients on antiplatelet therapy prior to carotid endarterectomy.

    References:

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