What is the recommended antiplatelet regimen for patients with an extracranial stent, specifically using Aspirin (acetylsalicylic acid) with Ticagrelor (antiplatelet agent)?

Antiplatelet Regimen for Extracranial Stent

For extracranial carotid or vertebral artery stenting, use aspirin 81-325 mg daily plus clopidogrel 75 mg daily—not ticagrelor—for at least 30 days post-stenting, then transition to single antiplatelet therapy indefinitely. 1

Why Clopidogrel, Not Ticagrelor

Clopidogrel is the P2Y12 inhibitor of choice for extracranial cerebrovascular stenting. 1 The guidelines explicitly state that ticagrelor is not recommended for extracranial carotid and vertebral artery disease due to limited guideline support and increased bleeding risk in this specific population. 1 This differs markedly from coronary stenting, where ticagrelor may be preferred for acute coronary syndromes. 2

The evidence supporting ticagrelor comes primarily from coronary intervention trials and posterior circulation stroke (not stenting) protocols. 3 While ticagrelor shows efficacy in intracranial aneurysm stenting 4 and coronary stenting 2, these data cannot be extrapolated to extracranial carotid/vertebral stenting where bleeding risk profiles and thrombotic mechanisms differ.

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
• This pre-loading period allows adequate platelet inhibition before arterial manipulation

Post-Stenting Dual Antiplatelet Therapy (DAPT)

• Continue aspirin 81-325 mg daily plus clopidogrel 75 mg daily for minimum 30 days post-stenting 1
• The 30-day duration is critical for endothelialization and prevention of acute/subacute stent thrombosis

Long-Term Maintenance

• After 30 days, transition to single antiplatelet therapy indefinitely 1
• Options include: aspirin 75-325 mg daily, clopidogrel 75 mg daily, or aspirin plus extended-release dipyridamole 25/200 mg twice daily 1
• For asymptomatic stenosis, aspirin 75-162 mg daily is preferred for cardiovascular protection 1

Critical Safety Considerations

Bleeding Risk Mitigation

• Add a proton pump inhibitor during DAPT to reduce gastrointestinal bleeding risk 1
• Maintain strict blood pressure control before and after stenting to minimize hemorrhagic complications 1
• Lower aspirin doses (81-100 mg) are reasonable after the initial period to reduce bleeding while maintaining efficacy 2

Stent Apposition Matters

Prioritize optimal stent wall apposition with appropriately sized (or slightly oversized) stents, especially in patients without robust collateral circulation. 5 Poor stent apposition dramatically increases thrombotic risk and may necessitate lifelong P2Y12 inhibitor therapy rather than the standard 30-day protocol. 5 A case report demonstrated hyperacute thrombosis within hours of missing a single ticagrelor dose in a patient with poorly apposed vertebral artery stents, even 6 months post-procedure. 5

Surveillance Protocol

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

Common Pitfalls to Avoid

• Do not use ticagrelor for routine extracranial stenting despite its use in coronary and posterior circulation stroke protocols 1
• Do not discontinue DAPT early in the first 30 days—this dramatically increases stent thrombosis risk 6, 5
• Do not use high-dose aspirin (>325 mg) long-term—doses above 100 mg increase bleeding without additional cardiovascular benefit 2
• Do not assume coronary stenting protocols apply to cerebrovascular stenting—the bleeding and thrombotic risk profiles differ substantially 1