OBJECTIVES: Transfemoral carotid artery stenting (TFCAS) and transcarotid artery revascularization (TCAR) are commonly used to treat carotid stenosis. However, the need for heparin alternatives during these procedures and their impact on outcomes remain unclear. This study evaluates the safety and efficacy of bivalirudin, the most commonly used heparin alternative, compared to heparin.

METHODS: The Vascular Quality Initiative (VQI) registry was queried for carotid artery stenting procedures performed from 2010 to 2022. Propensity-matched analyses compared outcomes between patients receiving intra-procedural heparin and those receiving bivalirudin. Primary outcomes were postoperative neurological events, including stroke or transient ischemic attack (TIA), and bleeding. Secondary outcomes included 30-day rates of reintervention and myocardial infarction, and mortality at 30 days and 1 year.

RESULTS: Among 80,172 carotid artery stenting procedures, 2,789 (3.47%) were performed with bivalirudin. In the heparin group, 24,797 (34.1%) underwent TFCAS with distal embolic protection, while 47,961 (65.9%) underwent TCAR with flow reversal. In the bivalirudin group, 2,494 (91.2%) underwent TFCAS, and 240 (8.8%) underwent TCAR. Propensity matching created two cohorts of 957 patients each. There were no significant differences in neurological events (OR: 1.44, 95% CI: 0.72-2.86; p=0.30), bleeding (OR: 1.0, 95% CI: 0.53-1.90; p=1.00), 30-day mortality (OR: 2.05, 95% CI: 0.62-6.85; p=0.24), or 1-year mortality (OR: 1.37, 95% CI: 0.84-2.24; p=0.21).

CONCLUSION: Bivalirudin is a safe and effective alternative to heparin for patients with contraindications to heparin undergoing carotid artery stenting. These findings suggest no significant differences in outcomes, supporting bivalirudin as a viable anticoagulation option.