Uninterrupted oral anticoagulation plus short-term single antiplatelet therapy in anticoagulated patients undergoing carotid artery stenting

BACKGROUND: Carotid artery stenting (CAS) is an established revascularization strategy for significant carotid stenosis aimed at preventing ischemic stroke. However, optimal antithrombotic management in anticoagulated patients undergoing CAS remains poorly defined, reflecting a rare and underexplored clinical scenario. We report a single-center experience evaluating a predefined peri-procedural strategy based on uninterrupted oral anticoagulation therapy (OAT) combined with single antiplatelet therapy (SAPT) and summarize the available literature. METHODS: We retrospectively analysed a prospectively maintained dataset including consecutive anticoagulated adults undergoing elective CAS between August 2020 and October 2025. According to institutional practice, SAPT was added to ongoing OAT at least 5 days before stenting and continued for at least 30 days. The primary outcome was 30-day net adverse clinical events (NACE). Analyses were primarily descriptive, and findings were contextualized through a literature review. RESULTS: Thirty anticoagulated patients undergoing CAS were included. Mean age was 77.4 ± 7.9 years, 76.7% were male, and non-valvular atrial fibrillation was the main indication for anticoagulation (73.3%); most patients (66.7%) received a direct oral anticoagulant. Within 30 days, NACE occurred in two patients (6.7%), consisting of one ischemic stroke due to subacute in-stent thrombosis and one major gastrointestinal bleeding. Among patients without early complications, stent patency at 30 days was confirmed in all cases, allowing SAPT discontinuation. Favourable functional outcome (modified Rankin Scale ≤2) was achieved in 86.7% of patients at 1 month and 83.3% at 3 months. Review of the literature identified a limited number of observational studies addressing antithrombotic management in this setting, with heterogeneous and often incompletely reported peri-procedural strategies. CONCLUSIONS: A standardized peri-procedural dual antithrombotic strategy based on uninterrupted OAT and short-term SAPT may be a feasible approach associated with acceptable short-term outcomes in anticoagulated patients undergoing elective CAS. This pragmatic approach may offer a clinically applicable alternative for peri-procedural management in selected patients, potentially mitigating bleeding risk. These real-world findings support clinical decision-making and call for validation in larger prospective studies.