Antiplatelet Therapy for Prevention of Thromboembolic Complications Associated with Coil Embolization of Unruptured Cerebral Aneurysms

Background: Antiplatelet agents are used during endovascular treatment of cerebral aneurysms to prevent thromboembolic complications. Objective: The aim of this study was to investigate the efficacy of clopidogrel for the prevention of thromboembolic complications during elective coil embolization of unruptured cerebral aneurysms. Methods: Sixty-three patients prospectively received oral clopidogrel 75mg/day from 3 days before and for 1 day after the procedure at our institute (Kohnan Hospital, Sendai, Japan) during 2007. Results: At 24 hours post-coiling, significantly less high-intensity areas, detected by MRI with diffusion-weighted imaging (MRI-DWI), were observed in clopidogrel-treated patients compared with a historical control cohort of aspirin (acetylsalicylic acid)-treated patients (13/63 [20.6%] vs 27/69 [39.1%]; p = 0.02), primarily due to a statistically significantly lower rate during repair of small (<10mm) lesions (p = 0.008).Also, the rate of periprocedural thromboembolic events was lower in the clopidogrel than the aspirin cohort (2/63 [3.2%] vs 5/69 [7.2%]; p = 0.3). Conclusions: Clopidogrel was generally well tolerated with no signs of hemorrhagic complications or liver dysfunction

Second asymptomatic carotid surgery trial (ACST-2) : a randomised comparison of carotid artery stenting versus carotid endarterectomy

Background: Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. Methods: ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. Findings: Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86-1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91-1·32; p=0·21). Interpretation: Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable