Antithrombotic Therapy in Carotid Artery and Intracranial Artery Stent

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Optimal platelet inhibition is critical in patients with carotid and intracranial artery stenosis undergoing carotid artery stenting (CAS) and intracranial artery stenting (ICS). Many reports have highlighted the importance of dual antiplatelet therapy (DAPT) in reducing adverse neurological outcomes without a significant increase in bleeding complications during CAS. DAPT has commonly used CAS and ICS, typically with aspirin and clopidogrel, but clopidogrel resistance occurs in approximately 20% of Japanese and other Asian populations. One solution to clopidogrel resistance is using adjunctive cilostazol to suppress the frequency of stroke events and in-stent restenosis after CAS. Other antiplatelet agents such as prasugrel, ticagrelor, cangrelor, and glycoprotein (GP) IIb/IIIa inhibitors are under investigation. The duration of DAPT after CAS remains controversial, as a longer duration of DAPT after CAS is associated with lower rates of readmission for stroke, but increased risk of hemorrhagic complications. Regarding antithrombotic therapy in CAS with concomitant atrial fibrillation, the use of direct oral anticoagulants plus a P2Y12 inhibitor may be suggested for the optimal safety and efficacy of antithrombotic management. For emergent CAS in acute ischemic stroke (AIS), intraprocedural DAPT loading and GP IIb/IIIa inhibitors, as necessary, may improve stent patency without increasing the risk of intracranial hemorrhage. In ICS, aggressive antiplatelet therapy based on an assessment of platelet aggregation is also important to improve clinical outcomes. In addition, rescue stenting for AIS caused by intracranial atherosclerotic stenosis-related large vessel occlusion is gaining attention. GP IIb/IIIa inhibitors have shown promise, but are not approved in Japan. In conclusion, DAPT is essential for the perioperative management of CAS and ICS. Specific perioperative antithrombotic management remains unclear, but the potential benefits of antithrombotic agents must be weighed against the corresponding increased risk of bleeding complications.