Is Crash Loading Acceptable in Carotid Artery Stenting?: Results of Antiplatelet Crash Loading vs. Semi-crash vs. Elective Loading in a Large Study Population

PURPOSE: In elective carotid artery stenting (CAS), antiplatelet therapy (APT) is crucial. Several international societies have provided guidelines for loading time and dosage in endovascular treatment; however, no recommendations have been made for urgent, nonthrombectomy-associated CAS without adequate loading time. Here, we investigated the short-term outcomes for APT-naïve patients receiving “crash loading” (CL) on the day of intervention, compared with those for patients wi APT onset 3–5 days (semi-CL) or more than 5 days before CAS (EL). METHODS: Outcomes of patients 30 days after CAS were evaluated in terms of the rates of in-stent thrombus, re-stenosis, stroke, hemorrhagic and thrombotic events, other periprocedural occurrences, in-hospital death and CAS-associated death. Patients’ biological, pathological and hemostatic factors were recorded and compared. RESULTS: A total of 1158 patients who received CAS at the authors’ neuroradiology institution were analyzed: 275 EL, 846 semi-CL, and 37 CL. The patients receiving CL had the lowest rate of stroke, but the highest rates of CAS-associated and in-hospital deaths, although the deaths were not necessarily associated with APT. In-stent thrombosis was the highest in the semi-CL group. The rates and types of periprocedural occurrences favored the CL group. CONCLUSION: With the medical regimen used in this study, urgent CAS with CL APT did not produce more ischemic, thrombotic and hemorrhagic complications than longer loading times. However, careful patient selection might be crucial and adequate loading times should remain the standard of care.