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Relationship between in-stent restenosis following carotid artery stenting and platelet reactivity to clopidogrel
  1. Min-Yong Kwon1,
  2. Sang Hyo Lee2,
  3. Yongjae Lee2,
  4. Young Deok Kim2,
  5. Si Un Lee2,
  6. Jae Seung Bang2,
  7. O-Ki Kwon2,3,
  8. Chang Wan Oh2,3,
  9. Seung Pil Ban2,3
  1. 1Department of Neurosurgery, Keimyung University Dongsan Hospital, Daegu, Republic of Korea
  2. 2Department of Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea
  3. 3Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea
  1. Correspondence to Dr Seung Pil Ban, Neurosurgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Korea (the Republic of); neurosurgeryban{at}


Objective To analyze the relationship between in-stent restenosis (ISR) following carotid artery stenting (CAS) and platelet clopidogrel reactivity confirmed by the P2Y12 reaction unit (PRU) and inhibition rate (IR).

Methods We retrospectively analyzed 171 patients who underwent CAS with extracranial carotid stenosis from January 2016 to December 2019. Dual antiplatelet therapy with 100 mg aspirin and 75 mg clopidogrel was started ≥5 days before CAS. Clopidogrel resistance was measured with the PRU and IR the day before CAS. The ISR degree was classified into R1, R2, and R3 (moderate to severe luminal stenosis of ≥50% or occlusion) by carotid CT angiography after 24–30 months. The degree of quantitative association between platelet reactivity and ISR R3 was determined by the receiver operating characteristic curve method. The optimal cut-off values of PRU and IR were derived using the maximum Youden index.

Results There were 33 R3 degrees of ISR (19.3%) and nine ipsilateral ischemic strokes (5.3%). The PRU and IR were different between R1+R2 degrees (176.4±50.1, 27.5±18.7%) and R3 degree (247.5±55.0, 10.3±13.4%) (P<0.001). The areas under the curves of PRU and IR were 0.841 and 0.781, and the optimal cut-off values were 220.0 and 14.5%, respectively. Multivariate logistic regression analysis showed that PRU ≥220 and IR ≤14.5% were significant predictive factors for ISR R3 (P<0.001 and P=0.017, respectively). ISR R3 was independently associated with ipsilateral ischemic stroke after CAS (P=0.012).

Conclusions High PRU (≥220) and low IR (≤14.5%) are related to ISR R3 following CAS, which may cause ipsilateral ischemic stroke.

  • platelets
  • atherosclerosis
  • drug
  • stent
  • CT angiography

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  • Contributors Conceptualization and design: M-YK, O-KK and SPB. Acquisition of data: M-YK. Analysis and interpretation of data: SHL, YL and KYD. Drafting the article: M-YK. Critically revising the article: SUL, JSB, OKK, CWO and SPB. Final approval of the manuscript: all authors. Study supervision and guarantor: SPB.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.