Cilostazol Might Help Prevent In-Stent Restenosis After Carotid-Artery Stenting

Treatment with the antiplatelet cilostazol may help prevent re-blockage of carotid-artery stents, but the finding is not statistically robust, according to new research from Japan.

Cilostazol is approved in the United States to treat leg pain associated with peripheral vascular disease. The phosphodiesterase 3 inhibitor improves endothelial function, inhibits platelet aggravation, acts as a vasodilator and mildly inhibits cell growth.

In the open-label Carotid Artery Stenting with Cilostazol Addition for Restenosis (CAS-CARE) study, presented February 21 at the American Stroke Association International Stroke Conference in Los Angeles, researchers tested the inhibitory effect of cilostazol on in-stent restenosis, compared with other antiplatelet medications, in 631 patients (mean age, 70; 88% men) scheduled for carotid-artery stenting.

By random assignment, 325 patients received cilostazol (50 mg or 100 mg, twice daily) and 306 received any antiplatelet agents other than cilostazol, starting 3 days before stenting and continuing for 2 years.

During 2 years of follow-up, in-stent restenosis occurred in 31 patients (9.5%) in the cilostazol group compared with 46 patients (15%) in the non-cilostazol group (hazard ratio, 0.64; 95% confidence interval, 0.41 to 1.03; P=0.056).

The rate of cardiovascular events was about 6% in both groups. Bleeding events occurred in 1.1% of the cilostazol group and 0.3% of the non-cilostazol group.

"This is the first trial to show potential effectiveness of medical management for the prevention of in-stent restenosis after carotid artery stenting," lead investigator Dr. Hiroshi Yamagami, director of the Department of Stroke Neurology at National Hospital Organization Osaka National Hospital in Japan, said in a news release from the conference.

Commenting on the study in a podcast, Dr. Mitchell Elkind, American Heart Association president-elect and chair of the Advisory Committee of the American Stroke Association, noted that carotid-artery stenting is being done "frequently now for patients with both symptomatic and asymptomatic carotid stenosis, and it's still not clear what the best way is to prevent the vessel from restenosing."

Cilostazol is not often used in the United States in the setting of stroke, but "it may have many benefits on the vessel wall that lead to its ability to reduce restenosis," said Dr. Elkind.

The CAS-CARE study found "some benefit to adding cilostazol, and this is perhaps an exciting result, with the degree of stenosis/restenosis dropping from about 15% to about 9% or so. However, the results were not statistically significant," Dr. Elkind noted.

Nonetheless, the CAS-CARE results "may prompt further study in this area."

The study had no commercial funding.

—Megan Brooks

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