Efficacy and safety of anticoagulant and antiplatelet therapies in the medical management of carotid free-floating thrombus: A systematic review

Background: The optimal treatment for carotid free-floating thrombus (CFFT) remains uncertain due to limited evidence, with no randomized clinical trials and scarce guidelines, such as ESVS 2023, favoring conservative management. Anticoagulation (ACT) and antiplatelet (APT) therapies are emerging as promising alternatives to high-risk surgical interventions. This systematic review aimed to evaluate the safety and efficacy of ACT and APT therapies for CFFT. Methods: A systematic search was performed across PubMed, Embase, Web of Science, and Cochrane databases. Safety and efficacy endpoints were assessed. A two-sample t-test compared baseline characteristics between groups, and a Chi-square test evaluated differences in categorical variables. Statistical significance was set at p < 0.05. Data were analyzed using R 4.3.0 with the meta package v.7.0-0. Results: Four studies met the inclusion criteria, involving 170 patients diagnosed with CFFT. The APT group included 96 patients (mean age 55.35 +/- 13.52 years; 56.25% male), and the ACT group included 74 patients (mean age 58.57 +/- 14.28 years; 51.35% male). Thrombus regression was slightly lower in APT (42%) compared to ACT (48%). Both groups showed similar rates of residual stenosis. Antiplatelet had fewer ischemic events within 30 days (none vs. 4% in ACT) and lower intracranial hemorrhage rates (3.3% vs. 5.4% in ACT) but higher mortality (6.3% vs. none in ACT). Conclusion: Both ACT and APT are effective for managing CFFT, each with distinct efficacy and safety profiles. However, randomized trials are necessary to better assess these therapies in CFFT management.