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Original research
Tirofiban versus aspirin to prevent in-stent thrombosis after emergent carotid artery stenting in acute ischemic stroke
  1. Manuel Medina-Rodriguez1,2,
  2. Diego Villagran1,
  3. Antonio Cristobal Luque-Ambrosiani3,
  4. Juan Antonio Cabezas-Rodríguez1,2,
  5. Leire Ainz-Gómez1,2,
  6. Pablo Baena Palomino1,2,
  7. Blanca Pardo-Galiana1,2,
  8. Aynara Zamora2,
  9. Asier de Albóniga-Chindurza2,4,
  10. Marta Aguilar-Perez2,4,
  11. Alejandro González2,4,
  12. Francisco Moniche1,2,
  13. Elena Zapata-Arriaza2,4
    1. 1Stroke Unit, Department of Neurology, Virgen del Rocio University Hospital, Sevilla, Spain
    2. 2Neurovascular Laboratory, Instituto de Biomedicina de Sevilla IBiS/University Hospital Virgen del Rocio/CSIC/University of Seville, Sevilla, Spain
    3. 3Department of Neurology, Virgen del Rocio University Hospital, Sevilla, Spain
    4. 4Department of Radiology, Interventional Neuroradiology, Virgen del Rocío University Hospital, Seville, Spain
    1. Correspondence to Dr Elena Zapata-Arriaza, Department of Interventional Neuroradiology, Hospital Universitario Virgen del Rocio, Seville, Seville, Spain; elena.zpt{at}


    Background Several antithrombotic treatments during emergent carotid artery stenting (eCAS) have been proposed, but an appropriate protocol to balance risk–benefit is not well known.

    Objective To investigate the efficacy and safety of tirofiban compared with aspirin in patients with acute ischemic stroke undergoing eCAS.

    Methods We conducted a retrospective single-center study of the prospective ARTISTA Registry, including patients with atherosclerotic internal carotid artery occlusion treated with eCAS. Two groups, according to antiplatelet drug, were studied: aspirin (250–500 mg single-dose) versus tirofiban (500 μg bolus+200 μg/h). Primary outcomes were the rate of in-stent thrombosis and symptomatic intracranial hemorrhage (sICH) within the first 24 hours.

    Results During the period 2019–2023, 181 patients were included, 103 received aspirin, 78 tirofiban; 149 (82.3%) had tandem lesions. The primary efficacy outcome occurred in 9 (9.4%) in the aspirin group, as compared with 1 (1.3%) in the tirofiban group (adjusted odds ratio (aOR)=0.11, 95% CI 0.01 to 0.98; P=0.048). The primary safety outcome was detected in 12 (11.7%) in the aspirin group, as compared with 2 (2.6%) in the tirofiban group (aOR=0.16, 95% CI 0.03 to 0.87; P=0.034). The tirofiban group presented a lower risk of parenchymal hemorrhage (18 (17.4%) vs 4 (5.2%), aOR=0.27, 95% CI 0.09 to 0.88; P=0.029) and an increased rate of excellent recanalization (expanded Treatment in Cerebral Infarction (eTICI) 2c–3) (50 (48.5%) vs 54 (69.2%); aOR=2.15, 95% CI 1.12 to 4.13; P=0.02). There were no differences in functional outcomes or mortality at 3 months.

    Conclusions Periprocedural antithrombotic therapy with tirofiban was associated with a lower risk of in-stent thrombosis and sICH at 24 hours from eCAS compared with aspirin. Prospective randomized clinical trials are needed to confirm our results.

    • stroke
    • stent
    • thrombectomy
    • platelets

    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

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    Data availability statement

    All data relevant to the study are included in the article or uploaded as supplementary information.

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    • X @baenap07, @ELeNaZapS

    • Contributors MM-R, FM, AG, and EZ-A conceived the idea and designed the study. MM-R, DV, and ACL-A collected data of carotid potency. MM-R and AZ performed the statistical analysis. MM-R, FM, JAC-R, LA-G, BP-G, and PBP performed carotid Doppler ultrasound scans. AdA-C, MA-P, AG, and EZA revised all data of the endovascular procedure. All authors recruited patients, collected data, and provided and cared for study patients. MM-R wrote the manuscript. FM and EZ-A supervised and guided writing of the main manuscript. EZ-A is responsible for the overall content as guarantor.

    • Funding This project was funded by the Instituto de Salud Carlos III (ISCIII) through the project PI21/01322 and co-funded by the European Union. The Spanish Clinical Research Network (SCReN-Code:21.033) also contributed to the study. The ITRIBiS project (Improving Translational Research Potential at the Institute of Biomedicine of Seville) has the registration number REGPOT-2013-1. MM-R was granted a Rio Hortega contract (CM21/00096). The project was included in the Spanish research network “Redes de Investigación Cooperativa Orientadas a Resultados en Salud” (RICORS-ICTUS) (RD21/0006/0015).

    • 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.