Effect of Chronic Antiplatelet and Anticoagulant Medication in Neck Hematoma and Perioperative Outcomes after Carotid Endarterectomy

Background: A retrospective analysis of neck hematoma, stroke, and mortality after symptom-atic and asymptomatic carotid endarterectomy (CEA) was conducted, to determine the most appropriate perioperative medication for these patients. Thirty-day outcomes of moderate and severe neck bleeding were also investigated.Methods: Patients undergoing CEA in a Vascular Surgery department were analyzed (2015e 2019). Preprocedure antithrombotic medication (from the 5 days prior to surgery) was identified. End point predictors were identified by univariate and multivariable analyses and adjusted for confounders.Results: A total of 304 CEA were included. Almost half of the included patients (49.67%) were under low-dose aspirin, 17.55% other single antiplatelet agent, 12.59% dual antiplatelet therapy, 8.61% anticoagulation, and 10.92% no antithrombotic therapy. There was a 8.22% rate of impor-tant hematoma, including 4.93% severe (requiring surgical exploration) hematomas and a 30 -day all-stroke incidence of 2.94% in symptomatic and 1.79% asymptomatic patients (P = 0.51). When compared to aspirin, severe hematoma was more prevalent with single clopi-dogrel or triflusal (relative risk [RR] 4.25, P = 0.11), dual antiplatelet group (RR 11.84, P = 0.002), and anticoagulation (RR 8.604, P = 0.02). Dual antiaggregation and anticoagulation did not confer postoperative stroke protection compared to single aspirin in either symptomatic or asymptomatic patients. Nonsignificant higher intrahospital mortality was noted in no medica-tion, dual antiplatelet, and anticoagulation groups in contrast to aspirin. Severe neck bleeding was associated with increased congestive heart failure (9.26-fold, P = 0.03) and longer hospital stay (11.20 +/- 24.69 days vs. 3.18 +/- 4.79 with no bleeding, P < 0.001), with a tendency for higher hospital readmission at 30 days (4.66-fold, P = 0.13). Mortality and stroke rates were similar. Conclusions: Double antiaggregation and anticoagulation did not confer better perioperative outcomes after elective CEA in our study. These regimens were associated with an increased risk of neck hematoma, especially severe bleeding, with similar rates of neurologic events in both symptomatic and asymptomatic patients and no mortality benefit. Monotherapy with aspirin appears to be the safest perioperative antithrombotic regimen for elective CEA.