Dual antiplatelet therapy after endovascular revascularization of infrainguinal arteries

Abstract

Endovascular therapy has been increasingly utilized for the treatment of lower extremity peripheral artery disease (PAD) given its shorter recovery time, overall safety, and non-inferiority compared to surgical repair.1 After endovascular interventions, antiplatelet therapy (anti-PLT) is frequently prescribed. The proximate goal of anti-PLT is to reduce the risk of acute limb ischemia caused by thrombosis and to potentially reduce the risk of major adverse cardiovascular events (MACE) due to atherosclerosis progression.2 Anti-PLT monotherapy has been shown to reduce MACE rates in patients with symptomatic PAD, although the absolute event rate reduction with monotherapy may be small.3 Thus, according to the TASC (TransAtlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease) recommendations, single anti-PLT should be started before any endovascular procedure and should be continued lifelong.4 However, data regarding the additive benefit of dual antiplatelet therapy (DAPT) and the optimal duration of anti-PLT are sparse, with only a few studies guiding decision-making.3,5 The American College of Cardiology and the American Heart Association (ACC/ AHA) recommend at least 1 month of combined therapy with aspirin and clopidogrel after infrainguinal endovascular procedures; however, the level of evidence for this recommendation is low (grade 2B).5 Moreover, in several trials investigating peripheral intervention devices, treatment with DAPT (i.e. aspirin and clopidogrel) was mandated for a time period ranging from 1 to 3 months, but this recommendation was again based primarily on expert consensus.6 Detailed anti-PLT guidelines for PAD are presented in Table 1. In the current study by Kim and colleagues,7 the authors conducted a retrospective analysis to describe the practice patterns of DAPT prescription following endovascular procedures for the treatment of lower extremity lesions and to determine which factors might predict discontinuation of anti-PLT therapy in real-world practice. In total, the current study included 23,420 patients and approximately 58% of the patients were discharged with DAPT.7 The study demonstrated that patients prescribed DAPT after endovascular intervention had higher odds of coronary artery disease (CAD), history of percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), and history of previous lower extremity vascular intervention. Subjects prescribed DAPT were also more likely to be prescribed statins, indicating overlap in optimal medical therapy. Thus, this study suggested that patients with cardiovascular risk factors and/or comorbidities were more likely to be prescribed DAPT at the time of hospital discharge after endovascular intervention. Interestingly, at 3, 12, and 24 months of follow-up, 70.47%, 56.49%, and 49.63% of these patients remained on DAPT, respectively. The high variation in actual DAPT duration demonstrated by this study may be driven by the lack of class I evidence supporting DAPT use, differences in revascularization strategies, and several patient comorbidities (i.e. cardiovascular factors).8 Consistent with this, prior studies have suggested that the presence of recognized CAD and/or diabetes drives most decision making among medical therapy of patients with PAD, rather than the recognition that PAD is associated with a high risk of MACE.9 Some studies regarding DAPT use among patients with symptomatic PAD (i.e. claudication, CLI) have shown reduced rates of MACE and mortality compared to aspirin monotherapy.10 The mechanism of this late benefit of DAPT is likely that it protects the patients from both limb adverse events and overall cardiovascular mortality.3 However, the benefits of DAPT must be balanced by the potential higher risk for bleeding complications, and, as such, in several individualized cases DAPT should be prescribed with caution (Table 2). Additionally, the clinical decision making for anti-PLT and antithrombotic therapy after endovascular intervention is becoming more complicated with the addition of directacting oral anticoagulants, such as rivaroxaban. The recent Cardiovascular Outcomes for People Using Anticoagula tion Strategies (COMPASS; ClinicalTrials.gov Identifier: NCT01776424) trial, comparing combined therapy with rivaroxaban and aspirin to monotherapy with either aspirin Dual antiplatelet therapy after endovascular revascularization of infrainguinal arteries