背景:已经提出了几种在急诊颈动脉支架置入术(eCAS)期间的抗血栓治疗方法,但是平衡风险-收益的适当方案并不为人所知。
目的:比较替罗非班与阿司匹林对急性缺血性卒中患者行eCAS的疗效和安全性。
方法:我们对前瞻性ARTISTA注册中心进行了回顾性单中心研究,包括接受eCAS治疗的动脉粥样硬化性颈内动脉闭塞患者。两组,根据抗血小板药物,进行了研究:阿司匹林(250-500mg单剂量)与替罗非班(500μg推注200μg/h)。主要结果是在最初24小时内支架内血栓形成和症状性颅内出血(sICH)的发生率。
结果:在2019-2023年期间,共纳入181例患者,103接受阿司匹林,78替罗非班;149(82.3%)有串联病变。阿司匹林组9例(9.4%)出现主要疗效转归,替罗非班组为1(1.3%)(校正比值比(aOR)=0.11,95%CI0.01~0.98;P=0.048).阿司匹林组中12例(11.7%)检测到主要安全性结果,替罗非班组为2(2.6%)(aOR=0.16,95%CI0.03至0.87;P=0.034)。替罗非班组出现实质出血的风险较低(18(17.4%)vs4(5.2%),aOR=0.27,95%CI0.09至0.88;P=0.029)和优良再通率增加(脑梗死扩大治疗(eTICI)2c-3)(50(48.5%)vs54(69.2%);aOR=2.15,95%CI1.12至4.13;P=0.02)。3个月时的功能结局或死亡率没有差异。
结论:与阿司匹林相比,替罗非班的围手术期抗血栓治疗与eCAS后24小时内支架内血栓形成和sICH的风险较低相关。需要前瞻性随机临床试验来证实我们的结果。
BACKGROUND: Several antithrombotic treatments during emergent carotid artery stenting (eCAS) have been proposed, but an appropriate protocol to balance risk-benefit is not well known.
OBJECTIVE: To investigate the efficacy and safety of tirofiban compared with aspirin in patients with acute ischemic stroke undergoing eCAS.
METHODS: We conducted a retrospective single-center study of the prospective ARTISTA Registry, including patients with atherosclerotic internal carotid artery occlusion treated with eCAS. Two groups, according to antiplatelet drug, were studied: aspirin (250-500 mg single-dose) versus tirofiban (500 μg bolus+200 μg/h). Primary outcomes were the rate of in-stent thrombosis and symptomatic intracranial hemorrhage (sICH) within the first 24 hours.
RESULTS: During the period 2019-2023, 181 patients were included, 103 received aspirin, 78 tirofiban; 149 (82.3%) had tandem lesions. The primary efficacy outcome occurred in 9 (9.4%) in the aspirin group, as compared with 1 (1.3%) in the tirofiban group (adjusted odds ratio (aOR)=0.11, 95% CI 0.01 to 0.98; P=0.048). The primary safety outcome was detected in 12 (11.7%) in the aspirin group, as compared with 2 (2.6%) in the tirofiban group (aOR=0.16, 95% CI 0.03 to 0.87; P=0.034). The tirofiban group presented a lower risk of parenchymal hemorrhage (18 (17.4%) vs 4 (5.2%), aOR=0.27, 95% CI 0.09 to 0.88; P=0.029) and an increased rate of excellent recanalization (expanded Treatment in Cerebral Infarction (eTICI) 2c-3) (50 (48.5%) vs 54 (69.2%); aOR=2.15, 95% CI 1.12 to 4.13; P=0.02). There were no differences in functional outcomes or mortality at 3 months.
CONCLUSIONS: Periprocedural antithrombotic therapy with tirofiban was associated with a lower risk of in-stent thrombosis and sICH at 24 hours from eCAS compared with aspirin. Prospective randomized clinical trials are needed to confirm our results.