A standardized peri-procedural dual antithrombotic strategy based on uninterrupted OAT and short-term SAPT may be a feasible approach associated with acceptable short-term outcomes in anticoagulated patients undergoing elective CAS.
Key Findings
Methods
The study population consisted of 30 anticoagulated patients undergoing elective carotid artery stenting at a single center over approximately five years.
Data were collected from a prospectively maintained dataset covering August 2020 to October 2025.
Mean age was 77.4 ± 7.9 years and 76.7% were male.
Non-valvular atrial fibrillation was the main indication for anticoagulation in 73.3% of patients.
Most patients (66.7%) received a direct oral anticoagulant.
The study was retrospective and analyses were primarily descriptive.
Methods
The institutional peri-procedural antithrombotic protocol consisted of uninterrupted oral anticoagulation therapy combined with single antiplatelet therapy added at least 5 days before stenting and continued for at least 30 days.
Oral anticoagulation therapy (OAT) was not interrupted around the procedure.
Single antiplatelet therapy (SAPT) was initiated at least 5 days pre-procedure.
SAPT was continued for at least 30 days post-procedure.
This strategy was applied to consecutive anticoagulated adults undergoing elective CAS.
The protocol differed from standard dual antiplatelet therapy (DAPT) used in non-anticoagulated patients.
Results
The 30-day net adverse clinical events (NACE) rate was 6.7%, comprising one ischemic stroke and one major bleeding event.
NACE occurred in two of 30 patients (6.7%) within 30 days.
One event was an ischemic stroke caused by subacute in-stent thrombosis.
One event was a major gastrointestinal bleeding episode.
The primary outcome was defined as 30-day NACE.
No additional early complications were reported beyond these two events.
Results
Stent patency at 30 days was confirmed in all patients who did not experience early complications.
Patency was confirmed in patients without early complications, allowing SAPT discontinuation at 30 days.
This supports the feasibility of the short-term SAPT strategy in this population.
Stent patency was assessed as part of the 30-day follow-up.
Results
Favorable functional outcomes were achieved in the majority of patients at both 1 and 3 months post-procedure.
Favorable functional outcome was defined as modified Rankin Scale (mRS) score ≤ 2.
86.7% of patients achieved mRS ≤ 2 at 1 month.
83.3% of patients achieved mRS ≤ 2 at 3 months.
The modest decline between 1 and 3 months may reflect the consequences of the ischemic stroke complication.
Discussion
A literature review identified only a limited number of observational studies addressing antithrombotic management in anticoagulated patients undergoing carotid artery stenting, with heterogeneous and often incompletely reported peri-procedural strategies.
The review confirmed this is a rare and underexplored clinical scenario.
Existing studies showed heterogeneous antithrombotic strategies without standardized reporting.
The paucity of evidence highlights the lack of guideline-level recommendations for this specific population.
The authors contextualized their findings through this literature review.
Conclusions
The authors concluded that a pragmatic dual antithrombotic strategy of uninterrupted OAT plus short-term SAPT may mitigate bleeding risk compared to triple therapy while maintaining acceptable ischemic outcomes.
The approach was described as potentially offering a 'clinically applicable alternative for peri-procedural management in selected patients, potentially mitigating bleeding risk.'
The strategy avoids full dual antiplatelet therapy (DAPT) in patients already on anticoagulation, which would constitute triple antithrombotic therapy.
The authors acknowledged the findings are from a single center with a small sample size.
Validation in larger prospective studies was called for.
What This Means
This research looked at a specific challenge in stroke prevention: how to safely manage blood-thinning medications in patients who need a carotid artery stenting procedure (a treatment to open a narrowed neck artery to prevent stroke) but are already taking anticoagulant drugs (blood thinners) for conditions like atrial fibrillation. Normally, stenting requires two antiplatelet drugs to prevent clots forming on the stent, but adding these to an existing anticoagulant creates 'triple therapy,' which significantly raises the risk of serious bleeding. The study tested a simpler approach: keeping patients on their anticoagulant throughout the procedure without interruption and adding just one antiplatelet drug for at least 30 days.
Among 30 patients treated this way at a single Italian hospital over five years, 6.7% experienced a serious adverse event within 30 days — one patient had a stroke due to a clot forming in the stent, and one had a major gastrointestinal bleed. All patients who did not have early complications had open, functioning stents at 30 days, at which point the antiplatelet drug was stopped. About 87% of patients had good functional ability (able to live independently) at one month, and 83% maintained this at three months. A review of existing medical literature found very few studies on this specific problem, and those that existed used inconsistent approaches.
This research suggests that continuing anticoagulation uninterrupted and adding only a single antiplatelet drug — rather than two — may be a practical and reasonably safe approach for carefully selected patients in this situation, potentially reducing bleeding risk compared to triple therapy. However, because this was a small, single-center study without a comparison group, the authors emphasize that larger prospective studies are needed to confirm these findings before this approach can be broadly recommended.