Efficacy and Safety of Anticoagulant and Antiplatelet Therapies in the Medical Management of Carotid Free-Floating Thrombus: a Systematic Review
Raphael Camerotte1, Marina Vilardo2, Filipe Virgilio Ribeiro3, Jhon E. Bocanegra-Becerra4, Ocilio Ribeiro Gonçalves5, Dominique Montecino6, Bruna Leles Vieira de Souza7, Luis Paleare8, Saul Dominici9, Arthur Corvelo10, Christian Fukunaga11, Lucas Pari Mitre12, Marcio Yuri Ferreira13, Ana Santos14, Anthony Hong14, Christian Ferreira15, David Gordon15, David Langer13, Yafell Serulle13
1Faculty of Medicine, Federal University of Rio de Janeiro, 2Department of Medicine, Catholic University of Brasilia, 3Barão de Mauá University Center, 4Univesidad Peruana Cayetano Heredia, 5Federal University of Piauí, 6Department of Neurology, Mayo Clinic, 7Department of Neurology, Massachusetts General Hospital, 8Pontifical Catholic University of Paraná, 9Federal University of Maranhão, 10University of Grande Rio, 11FMABC University Center, 12Santa Casa de São Paulo School of Medical Sciences, 13Department of Neurosurgery, Lenox Hill Hospital, 14University of Costa Rica, 15Department of Neurosurgery, Phelps Hospital
Objective:
To evaluate the safety and efficacy of anticoagulation (ACT) and antiplatelet (ATP) therapies for carotid free-floating thrombus (CFFT).
Background:
The optimal treatment for CFFT remains uncertain due to limited evidence, with no randomized clinical trials (RCTs) and scarce guidelines, such as ESVS 2023, favoring conservative management. ACT and antiplatelet APT therapies are emerging as promising alternatives to high-risk surgical interventions.
Design/Methods:
A systematic search following PRISMA guidelines was performed across PubMed, Embase, Web of Science, and Cochrane databases. Safety and efficacy endpoints were assessed. A two-sample t-test compared baseline characteristics, and a Chi-square test evaluated differences in categorical variables between groups. Statistical significance was set at p < 0.05. Data were analyzed using R 4.3.0 with the meta package v.7.0-0.
Results:
Four studies met the inclusion criteria, involving 170 patients diagnosed with CFFT. The APT group included 96 patients (mean age 55.35 ± 13.52 years; 56.25% male), and the ACT group included 74 patients (mean age 58.57 ± 14.28 years; 51.35% male). Median NIHSS ranged from 8-10 in the APT group versus 2-7 in the ACT group. The chi-square test of independence found no significant statistical difference between variables of sex, age, or ethnicity between the two groups. On the other hand, medical comorbidities differed among the ACT and APT groups (p<0.001). Thrombus regression was slightly lower in APT (42%) compared to ACT (48%). Both groups showed similar rates of residual stenosis. APT had fewer ischemic events within 30 days (none vs. 4% in ACT) and lower intracranial hemorrhage rates (3.3% vs. 5.4% in ACT) but higher mortality (6.3% vs. none in ACT).
Conclusions:
Both ACT and APT effectively manage CFFT with distinct efficacy and safety entities. However, RCTs are necessary to avoid selection bias, such as the lower NIHSS range in the ACT group, and to better assess these therapies in CFFT treatment.
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