Antiplatelet Therapy After Endovascular Revascularization for PAD

Study Questions:

What is the optimal strategy for antiplatelet therapy in patients with lower extremity peripheral artery disease (PAD) after endovascular revascularization?

Methods:

Between March 2008 and February 2013, 693 patients with lower extremity PAD underwent endovascular revascularization at two hospitals in South Korea. Patients received either mono-antiplatelet therapy (MAPT) or dual-antiplatelet therapy (DAPT) of varying durations. Patients were categorized into two treatment groups, one for patients receiving MAPT (of any duration) or DAPT <6 months and another with DAPT ≥6 months. The primary outcomes were major adverse cardiovascular events (MACE), major adverse limb events (MALE), and GUSTO major bleeding.

Results:

During a 5-year follow-up period, MACE occurred less frequently in patients receiving DAPT ≥6 months as compared to patients receiving MAPT or DAPT <6 months (17.3% vs. 31.3%, hazard ratio [HR], 0.44; 95% confidence interval [CI], 0.30-0.65). MALE occurred less frequently in patients receiving DAPT ≥6 months as compared to patients receiving MAPT or DAPT <6 months (21.5% vs. 43.7%, HR, 0.42; 95% CI, 0.30-0.58). Major bleeding events were infrequent, with no significant difference between DAPT durations of ≥6 months and MAPT or DAPT <6 months (2.3% vs. 3.5%, HR, 0.61; 95% CI, 0.17-2.18). Probability weighting and propensity matching did not significantly change estimated HR for MACE and MALE but did result in different HR for major bleeding (HR, 0.84 [95% CI, 0.21-3.33] for probability weighting and HR, 1.60 [95% CI, 0.30-8.76] for propensity matching).

Conclusions:

The authors concluded that use of DAPT for ≥6 months following endovascular revascularization for PAD was associated with lower 5-year MACE and MALE risk.

Perspective:

Despite a wealth of studies examining different combinations and durations of antiplatelet therapy in coronary revascularization, few high-quality studies have examined similar treatments in lower extremity PAD endovascular revascularization. Given all of the limitations of a retrospective study, this report from two South Korean hospitals suggests longer durations of DAPT (≥6 months) may be beneficial for most patients undergoing PAD revascularization. Ongoing, prospective studies will provide higher-quality evidence to guide this therapeutic choice. Perhaps the most important finding from this analysis is the overall high rate of MACE and MALE events in patients with PAD undergoing revascularization. Clinicians should focus on all secondary preventative measures (e.g., tobacco cessation, blood pressure control, lipid management) in addition to antiplatelet therapy in these high-risk patients.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Vascular Medicine

Keywords: Cardiology Interventions, Endovascular Procedures, Hemorrhage, Lower Extremity, Myocardial Revascularization, Peripheral Arterial Disease, Platelet Aggregation Inhibitors, Secondary Prevention, Vascular Diseases


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