Safety and efficacy of Ticagrelor for neuro-endovascular procedures in patients with Clopidogrel resistance – real life experience

Purpose

Patients receiving carotid artery stent (CAS) are prescribed dual anti-platelet therapy (DAPT) using Aspirin and Clopidogrel for 3 months. Clopidogrel resistance ranges from 13%-63%.Clinical outcomes utilizing DAPT with Ticagrelor in CAS are lacking. We compared Ticagrelor vs Clopidogrel following CAS to evaluate the safety and efficacy of Ticagrelor when compared to Clopidogrel.

Methods

All patients undergoing CAS placement received Aspirin with a loading dose (LD) of Clopidogrel (300mg) and are tested the following day for turbidimetric platelet aggregation. Patients found to be resistant (maximal aggregation > 50%) got LD of Ticagrelor (180mg).Two primary outcomes were net adverse clinical events - defined as death from any cause, myocardial infarction, definite stent thrombosis, stroke, or major bleeding defined according to PLATO criteria (primary combined outcome); and PLATO major or minor bleeding at 3 months. Secondary endpoints was occurrence of stent restenosis and cardiovascular mortality up to one year. We included a total of 325 patients, among them 215 (66%) received Clopidogrel and 110 (34%) received Ticagrelor.

Results

We found similar prevalence of cardiovascular and cerebrovascular events (12% vs 8% p=0.3; 11% vs 6% p=0.17 respectively). The bleeding rate was classified by PLATO criteria; minor and major bleeding event rates were similar in both groups (7% vs 11% p=0.19;2% vs 2% p=0.99 respectively). Cardiovascular mortality was similar in both groups ( 2% vs 1%, p=0.5). Stent restenosis was significantly lower in the Ticagrelor group (4% vs 0% p=0.03).

Conclusion

This is the first published study assessing the safety and efficacy of Ticagrelor in patients receiving CAS when compared to Clopidogrel. We found no difference in bleeding, cardiovascular, cerebrovascular or mortality events between the two groups. Stent restenosis was significantly lower in the Ticagrelor group when compared to the Clopidogrel group. Our results show that DAPT with Ticagrelor may be considered a safe, efficient and promising alternative regimen, especially in patients who are considered non-responders to Clopidogrel.