Correspondence on “Antithrombotic Treatment after Carotid Stenting in Patients with Concomitant Atrial Fibrillation”

We read with interest the excellent work by Pardo-Galiana et al,¹ which compared the safety and efficacy of the combination of direct oral anticoagulants and a P2Y12 inhibitor with 2 other antithrombotic regimens after carotid artery stent placement in patients with atrial fibrillation. The results indicated that a regimen of direct oral anticoagulants plus a P2Y12 inhibitor might confer a good safety profile with significantly lower rates of bleeding and optimal efficacy. However, we noticed that dual antiplatelet therapy (DAPT) was administered for only 1–3 months after stent implantation in the background and purpose, and patients in the DAPT group received DAPT for only 1 month before switching to aspirin alone. Few studies have reported DAPT for only 1 month after stent placement, and several randomized controlled trials have reported DAPT (aspirin 100 mg, plus clopidogrel 75 mg, daily) for 90 days in patients with symptomatic internal carotid artery stenosis who underwent carotid stent placement.^2,3

On the other hand, the assessment methods of stent thrombosis or restenosis in this study were not as rigorous or different as previously.⁴ To be precise, in-stent restenosis was defined as >50% stenosis by DSA or CTA at 6 months or 1 year within or immediately adjacent (within 5 mm) of the treated segment after interventional treatment of intracranial atherosclerotic disease.⁴ Carotid sonography can only detect the stenosis of the extracranial segment of the ICA, and is not suitable for the intracranial segment. Moreover, the short follow-up time (on days 1 and 30) is far from what is generally accepted (6 months or 1 year). Of course, there is no doubt that this retrospective study by Pardo-Galiana et al¹ has preliminarily confirmed that the combination of direct oral anticoagulants plus clopidogrel during the first month resulted in a lower risk of a bleeding event, with no increment of thromboembolic events. Further randomized studies are expected to provide more information on this.

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