What is the recommended antiplatelet regimen for extracranial stent placement, specifically with aspirin (acetylsalicylic acid) and ticagrelor?

Antiplatelet Regimen for Extracranial Stent Placement

For extracranial carotid or vertebral artery stenting, use aspirin 81-325 mg daily plus clopidogrel 75 mg daily—NOT ticagrelor—starting before the procedure and continuing for at least 30 days post-stenting. 1

Why Clopidogrel, Not Ticagrelor, for Extracranial Stents

The established guideline-based regimen for carotid artery stenting (CAS) specifically recommends dual antiplatelet therapy with aspirin (81-325 mg daily) plus clopidogrel (75 mg daily) for a minimum of 30 days after the procedure. 1 This is the only regimen with Class I evidence for extracranial cerebrovascular stenting. 1

Ticagrelor is NOT recommended for extracranial stenting because:

• All major guidelines for extracranial carotid and vertebral artery disease specify clopidogrel as the P2Y12 inhibitor of choice. 1
• Ticagrelor's guideline support is limited to acute coronary syndrome and coronary stent placement, not cerebrovascular interventions. 1
• The increased bleeding risk with ticagrelor (particularly intracranial hemorrhage) has not been justified by proven benefit in extracranial cerebrovascular stenting. 2

Specific Dosing Protocol

Pre-procedure loading:

• Initiate aspirin 81-325 mg daily plus clopidogrel 75 mg daily ideally 3-5 days before the procedure. 1
• For patients intolerant of clopidogrel, ticlopidine 250 mg twice daily may be substituted (not ticagrelor). 1

Maintenance therapy:

• Continue aspirin 81-325 mg daily plus clopidogrel 75 mg daily for a minimum of 30 days post-stenting. 1
• After 30 days, transition to single antiplatelet therapy (aspirin 75-325 mg daily OR clopidogrel 75 mg daily) indefinitely for secondary stroke prevention. 1

Duration Based on Clinical Context

For symptomatic extracranial stenosis (prior TIA or stroke):

• Minimum 30 days of dual antiplatelet therapy post-stenting. 1
• Lifelong single antiplatelet therapy thereafter (aspirin 75-325 mg daily, clopidogrel 75 mg daily, or aspirin plus extended-release dipyridamole 25/200 mg twice daily). 1

For asymptomatic extracranial stenosis:

• Same 30-day dual antiplatelet therapy protocol. 1
• Lifelong aspirin 75-162 mg daily for cardiovascular protection. 1

Critical Pitfalls to Avoid

Do not use ticagrelor for extracranial stenting despite its superiority in coronary interventions—the cerebrovascular bleeding risk profile differs substantially from coronary disease, and no guideline supports this substitution. 1, 2

Do not prematurely discontinue dual antiplatelet therapy before 30 days—early discontinuation significantly increases thrombotic stroke risk in the critical endothelialization period. 1

Do not use higher aspirin doses (>325 mg) with clopidogrel—this increases bleeding risk without additional efficacy, and doses of 81-100 mg are preferred when combined with P2Y12 inhibitors. 1, 3

Adjunctive Measures

• Add a proton pump inhibitor to reduce gastrointestinal bleeding risk during dual antiplatelet therapy. 1, 3
• Maintain strict blood pressure control before and after stenting to minimize hemorrhagic complications. 1
• Use embolic protection devices during the procedure when vascular anatomy permits. 1

Surveillance After Stenting

Perform non-invasive imaging (duplex ultrasound, CTA, or MRA) at 1 month, 6 months, and annually after revascularization to assess patency and detect restenosis or new lesions. 1 Once stability is established over several years, extend surveillance intervals or terminate when the patient is no longer a revascularization candidate. 1