Impact of preoperative dual antiplatelet therapy vs. aspirin monotherapy on perioperative outcomes in carotid endarterectomy patients: a retrospective cohort study

INTRODUCTION: The preoperative use of dual antiplatelet therapy (DAPT) in patients undergoing carotid endarterectomy (CEA) is controversial. AIM: This study aimed to compare perioperative major bleeding and major adverse cardiovascular events (MACEs) between patients receiving aspirin alone and those receiving DAPT (clopidogrel plus aspirin). METHOD: This retrospective cohort study included patients with carotid artery stenosis who underwent CEA between January 2020 and December 2024. Patients were grouped according to preoperative antiplatelet therapy (DAPT vs. aspirin), and inverse probability of treatment weighting (IPTW) was applied to adjust for baseline imbalances. The primary outcome was 30-day post-CEA major bleeding (neck hemorrhage requiring reoperation or intracranial hemorrhage). The secondary outcome was 30-day post-CEA MACEs (ischemic stroke, myocardial infarction, or death). Multivariate logistic regression was performed to identify the predictors of major bleeding. RESULTS: A total of 741 patients were included (aspirin, n = 504; DAPT, n = 237). Patients in the DAPT group had a higher prevalence of symptom, prior stroke, coronary artery disease, hyperlipidemia, and prior revascularization. After IPTW adjustment, DAPT was associated with a higher risk of major bleeding than Aspirin (OR 4.21, 95% CI 1.81-9.78), with no significant difference in MACEs (OR 1.49, 95% CI 0.57-3.85). Multivariate analysis confirmed DAPT as an independent predictor of major bleeding (OR 3.40, 95% CI 1.42-8.19, p = 0.006), whereas preoperative statin use was independently associated with a reduced risk (OR 0.13, 95% CI 0.03-0.51, p = 0.003). CONCLUSION: Compared with aspirin monotherapy, preoperative DAPT was associated with an increased risk of perioperative major bleeding without a reduction in perioperative MACEs in patients undergoing CEA. Larger multicenter prospective studies are needed to confirm these findings.