Dual Antiplatelet Therapy Prior to Carotid Endarterectomy Reduces Post-operative Embolisation and Thromboembolic Events: Post-operative Transcranial Doppler Monitoring is now Unnecessary

BackgroundThrombotic stroke following carotid endarterectomy (CEA) is preceded by high-grade embolisation (detected using transcranial Doppler (TCD)) and can be prevented by incremental doses of Dextran. However, this strategy is labour intensive and Dextran manufacture has now ceased. A randomised trial has suggested that a single 75 mg dose of Clopidogrel (administered the night before surgery in addition to daily 75 mg Aspirin) significantly reduces post-CEA embolisation. We hypothesized that this model of dual antiplatelet therapy might significantly reduce the need for adjuvant Dextran therapy.MethodsRetrospective audit of prospectively acquired data in 297 patients undergoing CEA between 01.08.2006 and 30.07.2009. All received routine Aspirin (75 mg daily) in addition to a single 75 mg dose of Clopidogrel the night before surgery. All underwent completion angioscopy and those with a temporal window (n = 270) underwent intra- and post-operative TCD monitoring.ResultsHigh rate embolisation requiring Dextran (>25 emboli in any 10 min period) occurred in only 1/270 patients (0.4%), significantly less than the 3.2% rate in historical controls where Clopidogrel was not administered. There were no peri-operative deaths, but 3/297 patients suffered non-disabling strokes (intra-operative extension of a pre-existing deficit, haemorrhage into lentiform nucleus after hypertensive crisis, contralateral embolic stroke). The overall 30-day death/stroke rate (1.0%) was not-significantly lower than the 2.6% rate observed in the preceding 821 patients.Conclusions75 mg Clopidogrel administered the night before surgery (in addition to daily 75 mg Aspirin) was associated with a significant reduction in post-operative embolisation and Dextran utilisation. No ipsilateral thromboembolic ischaemic events occurred in this series. As a consequence of this audit, one dose of 75 mg Clopidogrel will continue to be given pre-operatively (in addition to daily 75 mg Aspirin) and routine post-operative TCD monitoring has now ceased.