Should dual antiplatelet therapy (DAPT) be continued or held in a patient with carotid occlusion and stenosis undergoing elective endovascular stenting of the carotid artery?

Dual Antiplatelet Therapy Must Be Continued for Elective Carotid Artery Stenting

For patients undergoing elective endovascular carotid artery stenting, dual antiplatelet therapy (DAPT) must be initiated before the procedure and continued for at least 1-3 months post-procedure, with aspirin continued indefinitely thereafter. 1, 2, 3

Pre-Procedural DAPT Management

• DAPT should be initiated and maintained before carotid artery stenting (CAS), as 82% of centers performing CAS use pre-procedural DAPT as standard practice 1
• The recommended regimen consists of aspirin (75-100 mg daily) plus clopidogrel (75 mg daily) 4, 2
• Loading doses should be administered if the patient is not already on DAPT: clopidogrel 300-600 mg loading dose prior to the procedure 2, 5
• Pre-procedural DAPT significantly reduces neurological complications compared to aspirin alone (2% vs 16% 30-day neurological complication rate) 5

Peri-Procedural Management

• Continue both antiplatelet agents throughout the procedure without interruption 1, 5
• The combination of clopidogrel plus aspirin is superior to ticlopidine plus aspirin, with lower ischemic event rates (4.3% vs 13%) 2
• Never discontinue both antiplatelet agents simultaneously due to high risk of stent thrombosis 6

Post-Procedural DAPT Duration

The optimal duration is 90 days (3 months) of DAPT following carotid artery stenting, based on the most recent high-quality evidence:

• A 2025 nationwide cohort study of 12,034 CAS patients demonstrated that short-duration DAPT (90 days to <6 months) was non-inferior to long-duration DAPT (≥6 months) for the composite outcome of ischemic stroke, gastrointestinal bleeding, and intracranial hemorrhage (2.5% vs 2.1%, adjusted HR 0.869, p=0.337) 3
• 86% of centers continue DAPT for a mean duration of 3 months post-CAS in current practice 1
• After completing 3 months of DAPT, transition to aspirin monotherapy (75-100 mg daily) indefinitely 4, 1, 7

Critical Timing Considerations

Elective non-cardiac surgery requiring antiplatelet interruption should not be performed within the first month after carotid stenting 6:

• Surgery within 30 days of stenting is potentially harmful due to high stent thrombosis risk 4
• If time-sensitive surgery is required, it may be considered ≥3 months after stenting if surgical benefits outweigh thrombotic risks 4
• Aspirin should be continued perioperatively whenever possible, even if P2Y12 inhibitor must be held 4

Special Circumstances

For patients requiring oral anticoagulation:

• Triple therapy (DAPT plus anticoagulation) should be limited to maximum 6 months or omitted after hospital discharge, as it increases bleeding risk 2-3 fold 6
• Consider transitioning to aspirin plus anticoagulation after the initial high-risk period 6

For high bleeding risk patients:

• Shortened DAPT to 90 days is appropriate and evidence-based 3
• Mandatory gastric protection with proton pump inhibitor when using DAPT 6

Common Pitfalls to Avoid

• Do not perform elective CAS without pre-procedural DAPT loading - this significantly increases neurological complication rates 5
• Do not use aspirin monotherapy for CAS - dual antiplatelet therapy is mandatory for this procedure 1, 2, 5
• Do not continue DAPT beyond 3-6 months unless specific high-risk features exist - this increases bleeding risk without additional ischemic benefit 3
• Do not discontinue aspirin after stopping clopidogrel - aspirin should be continued lifelong for secondary prevention 1, 7