From the Guidelines
Plavix (clopidogrel) should be continued for at least 3 months after carotid endarterectomy in patients with symptomatic carotid stenosis, but can be stopped after surgery in those undergoing surgical revascularization, according to the most recent guidelines 1. The optimal duration for continuing Plavix after carotid endarterectomy varies based on individual patient factors. For most patients who undergo CEA, antiplatelet therapy with aspirin alone (typically 81-325 mg daily) is the standard recommendation for long-term use. If a patient was taking Plavix before surgery for other indications (such as recent coronary stenting or stroke), it should typically be resumed 24-48 hours after surgery once hemostasis is assured, and continued according to the original indication. In specific high-risk cases—such as patients with recurrent stenosis, multiple vascular risk factors, or those who experienced stroke while on aspirin therapy—some clinicians may prescribe Plavix for 1-3 months post-operatively or consider dual antiplatelet therapy with both aspirin and Plavix. The rationale for limiting routine Plavix use after CEA is that studies have not demonstrated clear additional benefit of clopidogrel over aspirin alone for preventing complications after carotid surgery, while the risk of bleeding complications is increased with dual antiplatelet therapy or Plavix alone compared to aspirin monotherapy 1. Key considerations include:
- The patient's individual risk factors and medical history
- The type of surgery performed (e.g. surgical revascularization vs. endovascular revascularization)
- The presence of symptomatic carotid stenosis
- The need for ongoing antiplatelet therapy for other indications (e.g. coronary stenting or stroke) 1. It is essential to weigh the potential benefits of Plavix against the increased risk of bleeding complications and to consider alternative treatment options, such as aspirin monotherapy, in patients who are at high risk of bleeding or have a history of bleeding complications 1.
From the Research
Duration of Plavix (Clopidogrel) after Carotid Endarterectomy
The optimal duration of Plavix (clopidogrel) after carotid endarterectomy is not well established. However, several studies provide insights into the use of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel in this context.
- A study published in 2016 2 found that short-term dual antiplatelet therapy with aspirin and clopidogrel after carotid endarterectomy might be associated with a lower incidence of restenosis. In this study, patients received 75 mg of clopidogrel for 30 days starting immediately after the surgical procedure.
- Another study published in 2010 3 found that dual antiplatelet therapy prior to carotid endarterectomy reduces post-operative embolisation and thromboembolic events. In this study, patients received a single 75 mg dose of clopidogrel the night before surgery in addition to daily 75 mg aspirin.
- A review of the literature published in 2019 4 found that low to medium dose aspirin (81-325 mg daily) is superior to higher doses (>650 mg daily) at preventing recurrent vascular events in patients undergoing endarterectomy. The use of peri-procedural aspirin-clopidogrel in patients undergoing endovascular treatment is based on one pilot trial, but appears safe.
- A study published in 2016 5 found that for carotid endarterectomy, only 31% of sites used dual antiplatelet therapy (DAPT) pre-operatively, 24% post-operatively with a mean post-procedural duration of 3 months (range 1-5), while 10% continued DAPT life-long.
Recommendations
Based on the available evidence, it appears that dual antiplatelet therapy with aspirin and clopidogrel may be beneficial in reducing the risk of restenosis and thromboembolic events after carotid endarterectomy. However, the optimal duration of clopidogrel therapy is not well established.
- The study published in 2016 2 suggests that 30 days of clopidogrel therapy may be sufficient to reduce the risk of restenosis.
- The study published in 2010 3 suggests that a single dose of clopidogrel the night before surgery may be beneficial in reducing post-operative embolisation and thromboembolic events.
- The review of the literature published in 2019 4 suggests that low to medium dose aspirin (81-325 mg daily) is superior to higher doses (>650 mg daily) at preventing recurrent vascular events in patients undergoing endarterectomy.
It is essential to note that these findings are based on limited evidence, and further studies are needed to determine the optimal duration of clopidogrel therapy after carotid endarterectomy. The decision to continue or discontinue clopidogrel therapy should be made on an individual basis, taking into account the patient's specific risk factors and medical history.