The Safety Of Triple Antiplatelet Therapy Under Thromboelastography (TEG) Guidance In Patients Undergoing Stenting For Extracranial And Or Intracranial Artery Stenosis

Background:To prevent thromboembolic events,double antiplatelet therapy(aspirin plus clopidogrel)has been pursued as a standard preparation while stenting for extracranial and/or intracranial artery stperioperative enosis.However,the incidence of thromboembolic events is still not satisfactory,which can be partly explained by the resistance of antiplatelet drugs.In multiple studies on percutaneous coronary intervention,triple antiplatelet therapy with cilostazol(TAT)has been considered to be a safe and effective alternative.However,thus far,little information has been available regarding TAT in patients undergoing stenting for ischemic cerebrovascular disease,largely due to the perceived risk of increased bleeding complications,especially intracranial haemorrhage,when antithrombotic effects are intensified.Objective:To investigate the safety of triple antiplatelet therapy(TAT)with cilostazol under the guidance of thromboelastography(TEG)in patients underwent stenting for extracranial and/or intracranial artery stenosis.Methods:Since routinely carried out pre-stenting TEG testing until June 2017 in the General Hospital of the PLA Rocket Force,a prospectively collected database was reviewed to identify patients who underwent stenting for extracranial and/or intracranial artery stenosis and showed resistance to aspirin and/or clopidogrel as assessed by pre-stenting thromboelastography(TEG)testing.Based on informed patient choice,patients were assigned to a TAT group and a dual antiplatelet therapy(DAT)group.Major complications were defined as thromboembolic events(transient ischemic attack(TIA),ischemic stroke,and stent thrombosis)or major bleeding events within 30 days,and minor complications were defined as extracranial bleeding that did not require vascular surgery or transfusion within 30 days.Results:Between January 2013 and June 2017,a total of 183 patients were identified.The incidence of major complications was significantly lower in the TAT group than in the DAT group(TAT group vs DAT group,1/110 vs 6/73;P=0.017).TIAs occurred in 4 patients,with 1 in the TAT group and 3 in the DAT group(1/110 vs 3/73;P=0.303).Ischemic strokes occurred in 3 patients in the DAT group(TAT group vs DAT group,P=0.062).No major bleeding events or stent thrombosis was recorded in either group.Two patients(one in each group,gastrointestinal bleeding)experienced minor complications that resolved without additional treatment(TAT group vs DAT group,1/110 vs 1/73;P>0.999).Conclusions:TAT under TEG guidance appears to be a safe antiplatelet strategy in patients undergoing stenting for extracranial and/or intracranial artery stenosis.By employing TAT under TEG guidance,favourable outcomes can be achieved in these patients.