A 66-year-old man with a history of hypertension, gastroesophageal reflux disease, hyperlipidemia, and current smoking presents with a worsening left leg pain that started 6 months earlier. Initially, the pain was associated with walking and resolved with rest; in the previous month, the pain has also been present at rest. He is diagnosed with chronic limb-threatening ischemia (CLTI) and evaluated for a revascularization intervention.
Upon evaluation, a suitable great saphenous vein for conduit is not found. He subsequently undergoes an endovascular lower extremity revascularization (LER) that is completed with no complications. Clopidogrel is added to his current medical treatment, which includes a statin, aspirin, proton pump inhibitor, and angiotensin-receptor blocker.
Which one of the following management steps will lower this patient's risk of subsequent severe acute limb ischemia (ALI)?
Show Answer
The correct answer is: C. Adding rivaroxaban 2.5 mg BID after LER.
After LER for symptomatic peripheral artery disease (PAD), ALI is frequent (7.8%) and associated with poor prognosis. Low-dose rivaroxaban 2.5 mg BID plus aspirin reduces ALI after LER, including ALI events associated with the most severe outcomes (all-cause mortality and major amputation). Benefit appears early, continues over time, and is consistent regardless of revascularization approach or clopidogrel use.1-3
In the VOYAGER PAD (Vascular Outcomes Study of ASA Along with Rivaroxaban in Endovascular or Surgical Limb Revascularization for PAD), surgical LER was associated with a higher rate of ALI after the procedure.
Supervised exercise training is recommended for symptoms of claudication (leg/calf pain that is associated with walking and abnormal ankle-brachial index [<0.9]).3
Lipid lowering is indicated in this patient according to the hyperlipidemia guidelines.2 Low-density lipoprotein level values are not given in the vignette, so adjustments are not relevant.
The recent BEST-CLI (Best Endovascular Versus Best Surgical Therapy in Patients With CLTI) trial found that surgical intervention for CLTI is superior to an endovascular approach when a suitable great saphenous vein for conduit is available.4 After a successful endovascular intervention, there is no indication for additional open surgery for risk management.
References
Hess CN, Debus ES, Nehler MR, et al. Reduction in acute limb ischemia with rivaroxaban versus placebo in peripheral artery disease after lower extremity revascularization: insights from VOYAGER PAD. Circulation 2021;144:1831-41.
Grundy SM, Stone NJ. 2018 American Heart Association/American College of Cardiology/Multisociety guideline on the management of blood cholesterol-secondary prevention. JAMA Cardiol 2019;4:589-91.
Bonaca MP, Bauersachs RM, Anand SS, et al. Rivaroxaban in peripheral artery disease after revascularization. N Engl J Med 2020;382:1994-2004.
Farber A, Menard MT, Conte MS, et al.; BEST-CLI Investigators. Surgery or endovascular therapy for chronic limb-threatening ischemia. N Engl J Med 2022;387:2305-16.
Log in to MyACC
