Is Pletal (cilostazol) effective after carotid stent placement?

From the Guidelines

Cilostazol (Pletal) is not typically recommended for routine use after carotid stenting, as the standard antithrombotic regimen following carotid stenting consists of dual antiplatelet therapy with aspirin and clopidogrel for at least 1 month, as recommended by the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1. The primary concern after carotid stenting is preventing stent thrombosis and embolic events, which are better addressed by the established dual antiplatelet regimen. Some key points to consider in the management of patients after carotid stenting include:

• Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is recommended for at least 1 month after carotid stent implantation, as stated in the 2024 ESC guidelines 1.
• Long-term aspirin or clopidogrel is recommended after carotid revascularization, as indicated in the 2024 ESC guidelines 1.
• Surveillance with duplex ultrasound (DUS) is recommended within the first month after carotid revascularization, as suggested in the 2024 ESC guidelines 1. Cilostazol, while effective for peripheral artery disease and intermittent claudication, has limited evidence supporting its use specifically for carotid stent protection, and its antiplatelet effects are generally considered less potent than clopidogrel for preventing stent thrombosis, as noted in the antithrombotic therapy in peripheral artery disease guidelines 1. Additionally, cilostazol can cause significant side effects, including headaches, palpitations, and tachycardia, which may be poorly tolerated in patients with carotid disease who often have concurrent cardiovascular conditions. If there are specific concerns about clopidogrel resistance or contraindications to standard therapy, alternative antiplatelet strategies should be discussed with a vascular specialist, taking into account the latest guidelines and evidence-based recommendations 1.

From the Research

Efficacy of Pletal Post Carotid Stent

• The use of antiplatelet therapy, including Pletal (cilostazol), after carotid stent placement is a common practice to prevent thromboembolic events 2, 3, 4, 5, 6.
• A study published in the AJNR. American journal of neuroradiology found that a regimen of direct oral anticoagulants plus a P2Y12 inhibitor, such as clopidogrel, might confer a good safety profile with significantly lower rates of bleeding and optimal efficacy in patients with carotid artery stent placement and atrial fibrillation 2.
• Another study published in the Journal of vascular surgery compared the efficacy and safety of perioperative dual antiplatelet therapy with ticagrelor versus clopidogrel in carotid artery stenting, and found that ticagrelor was associated with a potentially lower risk of stroke/death and bleeding complications after CAS in cases in which protamine was used 3.
• The current guidelines for prevention of secondary stroke recommend the broad use of antiplatelet therapy, including aspirin, clopidogrel, and dipyridamole, for secondary prevention of stroke in patients with non-cardioembolic ischemic stroke or transient ischemic attack 4, 5, 6.
• However, the use of dual antiplatelet therapy, including Pletal, is associated with an increased risk of major bleeding, particularly when the treatment is extended for greater than 30 days 6.

Safety Considerations

• The safety of using Pletal post carotid stent placement should be carefully considered, as it may increase the risk of bleeding complications 2, 3, 6.
• Patients with a history of bleeding disorders or those taking anticoagulant medications should be closely monitored when using Pletal post carotid stent placement 2, 3, 6.
• The use of Pletal should be individualized based on the patient's stroke characteristics, time from symptom onset, and patient-specific predisposition to develop hemorrhagic complications 6.