Safety and Efficacy of a Direct Oral Anticoagulant and Clopidogrel Versus Aspirin and Clopidogrel in Carotid Artery Stenting: A Propensity-Scored Analysis

BACKGROUND AND OBJECTIVES: Dual antiplatelet therapy is the gold standard regimen after carotid artery stenting (CAS). However, optimal regimens in patients undergoing this procedure with preexisting conditions requiring anticoagulation remain largely unknown. Here, we compare the safety and efficacy of combining a direct oral anticoagulant (DOAC) with clopidogrel vs aspirin with clopidogrel in patients undergoing CAS. METHODS: We conducted a retrospective cohort comparison study of 469 consecutive patients with carotid artery stenosis who underwent CAS and were prescribed either a DOAC plus clopidogrel or aspirin plus clopidogrel. Propensity scores were generated based on baseline characteristics with an absolute standardized difference of ≥0.20 between cohorts. Patients were matched in a 1:1 ratio using propensity score matching based on the calculated propensity scores. Safety and efficacy outcomes were compared. RESULTS: The study cohort consisted of 419 patients treated with aspirin and clopidogrel and 50 patients treated with a DOAC and clopidogrel. There was no significant difference in the primary safety outcome, total periprocedural complication rate, between cohorts before and after matching. Overall bleeding complications through femoral access were significantly lower in the DOAC plus clopidogrel group after matching (0.0% vs 11.4%, P = .043). Additional secondary safety outcomes and all efficacy outcomes (symptomatic in-stent stenosis, total in-stent stenosis, and retreatment) were not significantly different between groups. CONCLUSION: In this study, we found that a DOAC plus clopidogrel exhibits similar safety and efficacy profiles as compared with aspirin plus clopidogrel for patients undergoing CAS. Although bleeding complications through femoral access were significantly lower in the DOAC plus clopidogrel group, further studies are needed to clarify this finding.