Why do vascular surgeons recommend a statin (HMG-CoA reductase inhibitor), Aspirin (Acetylsalicylic Acid, ASA), and Plavix (Clopidogrel) before a TransCarotid Artery Revascularization (TCAR) procedure?

Preoperative Medical Optimization for TCAR

Vascular surgeons require statin, aspirin, and clopidogrel before TCAR to reduce perioperative stroke, myocardial infarction, and death—the same evidence-based strategy proven effective for all carotid revascularization procedures. 1

Dual Antiplatelet Therapy (Aspirin + Clopidogrel)

DAPT is recommended for all patients undergoing carotid revascularization, including TCAR, to reduce both symptomatic and asymptomatic cerebral embolization. 1

• Aspirin and clopidogrel together reduce transcranial Doppler-detected emboli during carotid procedures without increasing bleeding complications or transfusion requirements. 1
• The 2024 ESC guidelines specifically recommend DAPT for symptomatic carotid stenosis patients for at least 3 months, with continuation through endovascular procedures like TCAR. 1
• For patients undergoing endovascular carotid revascularization (which includes TCAR), DAPT should continue for 4 weeks after the procedure. 1
• DAPT reduces asymptomatic cerebral embolization and stroke recurrence in the early phase of symptomatic carotid disease. 1

Aspirin Alone

• Aspirin should be continued perioperatively in all patients at moderate-to-high cardiovascular risk, including those with prior MI, stroke, or coronary stents. 2
• For vascular surgery specifically, preoperative aspirin is routinely used and associated with improved peripheral bypass graft patency. 1
• Aspirin continuation does not increase major bleeding risk in carotid procedures. 1

Clopidogrel Management

• Clopidogrel loading prior to stenting is standard practice for carotid stenting procedures. 1
• The combination of aspirin and clopidogrel is more effective than aspirin alone in reducing asymptomatic embolization in patients with carotid stenosis. 1
• Resume both aspirin and clopidogrel within 24 hours after surgery when adequate hemostasis is achieved. 2

Statin Therapy

Statins dramatically reduce perioperative mortality and stroke risk in carotid procedures through pleiotropic vascular protective effects beyond cholesterol lowering. 1

• Statin users have 80% lower risk of peri-procedural death (0.2% vs 1.3%) after carotid endarterectomy compared to statin-naive patients. 1
• A large VQI analysis of 97,835 CEAs showed statin users had lower in-hospital stroke or death (1.4% vs 1.7%) and significantly lower 5-year mortality (10% vs 15%). 1
• European guidelines recommend continuing statins before and after all carotid revascularization procedures. 1
• Intensive statin therapy targeting LDL-C <55 mg/dL is advised for all patients with significant carotid atherosclerotic disease. 1

Mechanism of Benefit

• The benefit appears related to non-cholesterol-lowering pleiotropic effects including endothelial stabilization, anti-inflammatory properties, and plaque stabilization. 3
• These effects reduce perioperative cardiovascular morbidity across all major vascular surgery types. 3

Combined Therapy Benefits

The combination of aspirin, beta-blockers, and statins (ABBS) provides superior risk reduction compared to any single agent alone in high-risk vascular surgery patients. 4

• In high-risk patients (RCRI ≥3) undergoing major vascular surgery, ABBS therapy resulted in 3-fold lower MI incidence (2.5% vs 7.8%) and 8-fold lower 12-month mortality (5.9% vs 37.5%). 4
• After propensity adjustment, aspirin (HR 0.35), statins (HR 0.36), and beta-blockers (HR 0.65) each independently improved 12-month survival. 4
• Aspirin did not predict severe or moderate bleeding in this high-risk cohort. 4

TCAR-Specific Context

TCAR registry data shows excellent outcomes (99.7% technical success, <3% 30-day stroke/death, <1% MI) when performed with optimal medical therapy. 1

• The low complication rates reported in TCAR registries reflect contemporary practice that includes routine use of DAPT and statins. 1
• TCAR's 1-year stroke or death rate of 6.4% compares favorably to transfemoral carotid stenting (9.7%) and is similar to CEA (5.2%). 1

Common Pitfalls to Avoid

• Do not discontinue aspirin before TCAR—vascular procedures require continuation of aspirin throughout the perioperative period. 2
• Do not delay statin initiation—if time permits before surgery, start statins preoperatively as benefits are demonstrable even with short-term use. 1, 3
• Do not stop clopidogrel after TCAR—unlike CEA where clopidogrel can be stopped post-operatively, endovascular procedures require 4 weeks of DAPT continuation. 1
• Ensure adequate medication reconciliation—patients may not report over-the-counter NSAIDs with antiplatelet effects. 2
• Do not withhold therapy due to bleeding concerns—the thrombotic risk of carotid procedures far exceeds bleeding risk when DAPT is used appropriately. 1, 4