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Mono or Dual Antiplatelet Therapy for Treating Patients with Peripheral Artery Disease after Lower Extremity Revascularization: A Systematic Review and Meta-Analysis. Pharmaceuticals (Basel) 2022; 15:ph15050596. [PMID: 35631422 PMCID: PMC9144146 DOI: 10.3390/ph15050596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/02/2022] [Accepted: 05/09/2022] [Indexed: 12/24/2022] Open
Abstract
The efficacy of dual antiplatelet therapy (DAPT) for patients with peripheral artery disease (PAD) after lower-limb intervention remains controversial. Currently, the prescription of DAPT after an intervention is not fully recommended in guidelines due to limited evidence. This study compares and analyzes the prognosis for symptomatic PAD patients receiving DAPT versus monotherapy after lower-limb revascularization. Up to November 2021, PubMed/MEDLINE, Embase, and Cochrane databases were searched to identify studies reporting the efficacy, duration, and bleeding complications when either DAPT or monotherapy were used to treat PAD patients after revascularization. Three randomized controlled trials and seven nonrandomized controlled trials were included in our study. In total, 74,651 patients made up these ten studies. DAPT in PAD patients after intervention was associated with lower rates of all-cause mortality (HR = 0.86; 95% CI, 0.79−0.94; p < 0.01), major adverse limb events (HR = 0.60; 95% CI, 0.47−0.78; p < 0.01), and major amputation (HR = 0.78; 95% CI, 0.64−0.96) when follow-up was for more than 1-year. DAPT was not associated with major bleeding events when compared with monotherapy (OR = 1.22; 95% CI, 0.69−2.18; p = 0.50) but was associated with a higher rate of minor bleeding as a complication (OR = 2.54; 95% CI, 1.59−4.08; p < 0.01). More prospective randomized studies are needed to provide further solid evidence regarding the important issue of prescribing DAPT.
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Ipema J, Welling RHA, Bakker OJ, Bokkers RPH, de Vries JPPM, Ünlü Ç. Short-Term Clinical Outcomes of Single Versus Dual Antiplatelet Therapy after Infrainguinal Endovascular Treatment for Peripheral Arterial Disease. J Clin Med 2020; 9:jcm9113515. [PMID: 33143046 PMCID: PMC7693004 DOI: 10.3390/jcm9113515] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 10/23/2020] [Accepted: 10/27/2020] [Indexed: 11/16/2022] Open
Abstract
After infrainguinal endovascular treatment for peripheral arterial disease (PAD), it is uncertain whether single antiplatelet therapy (SAPT) or dual antiplatelet therapy (DAPT) should be preferred. This study investigated major adverse limb events (MALE) and major adverse cardiovascular events (MACE) between patients receiving SAPT and DAPT. Patient data from three centers in the Netherlands were retrospectively collected and analyzed. All patients treated for PAD by endovascular revascularization of the superficial femoral, popliteal, or below-the-knee (BTK) arteries and who were prescribed acetylsalicylic acid or clopidogrel, were included. End points were 1-, 3-, and 12-month MALE and MACE, and bleeding complications. In total, 237 patients (258 limbs treated) were included, with 149 patients receiving SAPT (63%) and 88 DAPT (37%). No significant differences were found after univariate and multivariate analyses between SAPT and DAPT on 1-, 3-, and 12-month MALE and MACE, or bleeding outcomes. Subgroup analyses of patients with BTK treatment showed a significantly lower 12-month MALE rate when treated with DAPT (hazard ratio 0.33; 95% confidence interval 0.12-0.95; p = 0.04). In conclusion, although patient numbers were small, no differences were found between SAPT and DAPT regarding MALE, MACE, or bleeding complications. DAPT should, however, be considered over SAPT for the subgroup of patients with below-the-knee endovascular treatment.
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Affiliation(s)
- Jetty Ipema
- Department of Surgery, Northwest Clinics, Wilhelminalaan 12, 1815 JD Alkmaar, The Netherlands;
- Department of Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands; (R.H.A.W.); (O.J.B.)
- Correspondence:
| | - Rutger H. A. Welling
- Department of Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands; (R.H.A.W.); (O.J.B.)
| | - Olaf J. Bakker
- Department of Surgery, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands; (R.H.A.W.); (O.J.B.)
| | - Reinoud P. H. Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands;
| | - Jean-Paul P. M. de Vries
- Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands;
| | - Çagdas Ünlü
- Department of Surgery, Northwest Clinics, Wilhelminalaan 12, 1815 JD Alkmaar, The Netherlands;
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Ipema J, Brand AR, DE Borst GJ, DE Vries JP, ÜnlÜ Ç. Antiplatelet and anticoagulation therapy after revascularization for lower extremity artery disease: a national survey and literature overview. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 62:59-70. [PMID: 33112125 DOI: 10.23736/s0021-9509.20.11402-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Antiplatelet therapy (APT) after interventions for lower extremity artery disease (LEAD) is recommended. However, (inter)national guidelines vary on type and duration of APT. This report aimed to present the results of a survey on antithrombotic prescribing patterns after lower limb interventions in the Netherlands and an overview of the available literature on this topic. METHODS Vascular surgeons from the Dutch Society for Vascular Surgery and interventional radiologists from the Dutch Society for Interventional Radiology received an online survey on the type and duration of antithrombotic medication after lower limb interventions. RESULTS Surveys were completed by 139 of 285 vascular surgeons (49%) and 24 of 288 (8%) interventional radiologists. Clopidogrel was the most prescribed drug after iliac percutaneous transluminal angioplasty (PTA) (77%), femoral PTA (77%), femoral PTA with drug-coated balloon (66%), and femoropopliteal (80%) and femorocrural (51%) prosthetic bypasses. Dual APT (DAPT), consisting of aspirin and clopidogrel, was most often prescribed after femoral PTA with stenting (56%) and crural PTAs (55% without stent, 73% with stent). Vitamin K antagonists were most often prescribed after femoropopliteal (83%) and femorocrural (80%) venous bypasses. Aspirin monotherapy prescription varied from 1% to 8% after interventions. Many interventional radiologists responded that they only advise in medication prescription but do not prescribe themselves. CONCLUSIONS Prescription of antiplatelet and anticoagulation therapy in LEAD patients after femoral and crural interventions varies widely among Dutch vascular surgeons, mostly between clopidogrel and DAPT. The duration of DAPT is also highly variable. These results reflect low-level evidence and discrepancy in current guideline recommendations.
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Affiliation(s)
- Jetty Ipema
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, the Netherlands -
| | - Aarent R Brand
- Division of Vascular Surgery, Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Gert J DE Borst
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, the Netherlands
| | - Jean-Paul DE Vries
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, the Netherlands
| | - Çağdaş ÜnlÜ
- Department of Vascular Surgery, Northwest Clinics, Alkmaar, the Netherlands
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Singh N, Ding L, Magee GA, Shavelle DM, Kashyap VS, Garg PK. Discharge Prescription Patterns for Antiplatelet Therapy Following Lower Extremity Peripheral Vascular Intervention. Circ Cardiovasc Interv 2020; 13:e008791. [PMID: 32791948 DOI: 10.1161/circinterventions.119.008791] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Despite current guidelines suggesting a benefit for dual antiplatelet therapy (DAPT) following peripheral vascular intervention (PVI), there are limited data on antiplatelet prescribing patterns post-procedure. We attempted to determine variables associated with DAPT prescription following lower extremity PVI. METHODS Retrospective analysis of patients undergoing lower extremity PVI in the Vascular Quality Initiative (2017-2018) was performed. Participants not on anticoagulation or DAPT before the procedure were considered for the final analysis. Postdischarge antiplatelet therapy regimen rates were determined (none, aspirin only, P2Y12 inhibitor only, and DAPT). Multivariate logistic regression was performed to determine variables associated with DAPT initiation compared with those discharged on single-agent or no antiplatelet therapy. RESULTS A total of 16 597 procedures were included for analysis, with 49% initiated on DAPT post-PVI. Male sex (odds ratio [OR], 1.12 [95% CI, 1.05-1.20]), smoking (OR, 1.20 [95% CI, 1.09-1.32]), and coronary artery disease (OR, 1.19 [95% CI, 1.11-1.27]) were associated with an increased likelihood of post-PVI DAPT prescription. Procedures requiring multiple types of interventions (OR, 1.28 [95% CI, 1.15-1.42]), stent placement (OR, 1.16 [95% CI, 1.06-1.27]), and with complications (OR, 1.31 [95% CI, 1.14-1.52]) were also positively associated with DAPT prescription. CONCLUSIONS In patients not already receiving anticoagulation or on DAPT at the time of lower extremity PVI, prescription of DAPT following intervention is ≈50%. Multiple factors were associated with the decision for DAPT versus single antiplatelet therapy, and further study is required to understand how this affects postintervention adverse limb and cardiovascular events.
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Affiliation(s)
- Nikhil Singh
- Section of Cardiology, Department of Medicine, University of Chicago, IL (N.S.).,Department of Internal Medicine (N.S.), University of Southern California Keck School of Medicine, Los Angeles
| | - Li Ding
- Department of Preventive Medicine (L.D.), University of Southern California Keck School of Medicine, Los Angeles
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy (G.A.M.), University of Southern California Keck School of Medicine, Los Angeles
| | - David M Shavelle
- Division of Cardiology (D.M.S., P.K.G.), University of Southern California Keck School of Medicine, Los Angeles
| | - Vikram S Kashyap
- Division of Vascular Surgery and Endovascular Therapy, University Hospitals Cleveland Medical Center, OH (V.S.K.)
| | - Parveen K Garg
- Division of Cardiology (D.M.S., P.K.G.), University of Southern California Keck School of Medicine, Los Angeles
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Giannopoulos S, Armstrong EJ. Dual antiplatelet therapy after endovascular revascularization of infrainguinal arteries. Vasc Med 2019; 24:536-538. [PMID: 31686620 DOI: 10.1177/1358863x19880601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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Kim TI, Chen JF, Orion KC. Practice patterns of dual antiplatelet therapy after lower extremity endovascular interventions. Vasc Med 2019; 24:528-535. [DOI: 10.1177/1358863x19880602] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Antiplatelet therapy is commonly prescribed following endovascular interventions. However, there is limited data regarding the regimen and duration of antiplatelet therapy following lower extremity endovascular interventions. The aim of this study was to investigate the practice patterns of dual antiplatelet therapy (DAPT) after lower extremity endovascular interventions. We identified all patients who received an endovascular intervention in the Vascular Study Group of New England (VSGNE) registry from 2010 through 2018. The antiplatelet regimen was examined at the time of discharge and follow-up. Variables predicting discharge antiplatelet therapy and duration of antiplatelet therapy were investigated. There were 13,510 (57.69%) patients discharged on DAPT, 8618 (36.80%) patients discharged on single antiplatelet therapy, and 1292 (5.51%) patients discharged without antiplatelet therapy. Patients with coronary artery disease (CAD), prior vascular bypass and endovascular intervention, preoperative statin use, stent placement compared with angioplasty, and femoropopliteal and tibial treatment were associated with higher odds of being discharged with DAPT compared with no antiplatelet therapy and single antiplatelet therapy. Of the patients discharged on DAPT who were followed up at 9–12 months and 21–24 months, 56.49% and 49.63% remained on DAPT, respectively. Only a narrow margin of the patient majority undergoing endovascular interventions was discharged with DAPT, suggesting that only a small proportion of patients undergoing endovascular intervention remain on DAPT long-term. As the number of peripheral vascular interventions continues to grow, further studies are crucial to identify the optimal duration of DAPT.
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Affiliation(s)
- Tanner I Kim
- Yale University, Department of General Surgery, Division of Vascular Surgery, New Haven, CT, USA
| | - Julia F Chen
- Yale University, Department of General Surgery, Division of Vascular Surgery, New Haven, CT, USA
| | - Kristine C Orion
- The Ohio State University, Department of Surgery, Division of Vascular Surgery, Columbus, OH, USA
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Beiswenger AC, Jo A, Harth K, Kumins NH, Shishehbor MH, Kashyap VS. A systematic review of the efficacy of aspirin monotherapy versus other antiplatelet therapy regimens in peripheral arterial disease. J Vasc Surg 2018; 67:1922-1932.e6. [DOI: 10.1016/j.jvs.2018.02.047] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 02/27/2018] [Indexed: 10/16/2022]
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Thott O, Granath F, Malmstedt J, Wahlgren CM. Editor's Choice – Dual Antiplatelet Therapy Improves Outcome in Diabetic Patients Undergoing Endovascular Femoropopliteal Stenting for Critical Limb Ischaemia. Eur J Vasc Endovasc Surg 2017; 53:403-410. [DOI: 10.1016/j.ejvs.2016.12.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 12/03/2016] [Indexed: 01/01/2023]
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Dual antiplatelet therapy is associated with prolonged survival after lower extremity revascularization. J Vasc Surg 2016; 64:1633-1644.e1. [PMID: 27575814 DOI: 10.1016/j.jvs.2016.05.098] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 05/23/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) after coronary stenting prolongs survival by preventing both in-stent thrombosis and other cardiovascular atherothrombotic events. Patients with peripheral artery disease (PAD) typically have a heavy burden of unrevascularized coronary artery disease and also stand to benefit from increased atherothrombotic protection with DAPT. The potential benefit of DAPT compared with aspirin alone in patients with PAD is not well described. METHODS We identified all patients undergoing an initial elective lower extremity revascularization (bypass or endovascular) from 2003 to 2016 in the Vascular Quality Initiative registry discharged on aspirin or aspirin plus a thienopyridine antiplatelet agent (DAPT). We first estimated models predicting the likelihood of receiving DAPT and then used inverse probability weighting to account for baseline differences in the likelihood of receiving DAPT and compared late survival. For sensitivity analysis, we also performed Cox proportion hazard modeling on the unweighted cohorts and generated adjusted survival curves. RESULTS We identified 57,041 patients undergoing lower extremity revascularization (28% bypass). Of 15,985 bypasses (69% for critical limb ischemia [CLI]), 38% were discharged on DAPT. Of 41,056 endovascular interventions (39% for CLI), 69% were discharged on DAPT. Analyses using inverse probability weighting demonstrated a small survival benefit to DAPT at 1 year for bypass (93% vs 92% [P = .001]) and endovascular interventions (93% vs 92% [P = .005]) that was sustained through 5 years of follow-up (bypass, 80% vs 78% [P = .004]; endovascular, 76% vs 73% [P = .002]). When stratified by severity of PAD, DAPT had a survival benefit for patients with CLI undergoing bypass (5 years, 70% vs 66% [P = .04]) and endovascular intervention (5 years, 71% vs 67% [P = .01]) but not for patients with claudication (bypass, 89% vs 88% [P = .36]; endovascular, 87% vs 85% [P = .46]). The protective effect of DAPT was similar when using Cox proportional hazard models after bypass (hazard ratio, 0.81 [95% confidence interval, 0.72-0.90]) and endovascular intervention (hazard ratio, 0.89 [95% confidence interval, 0.83-0.95]). CONCLUSIONS DAPT at time of discharge was associated with prolonged survival for patients with CLI undergoing lower extremity revascularization but not for those with claudication. Further research is needed to quantify the risks associated with DAPT and to identify subgroups at increased risk of thrombotic and bleeding complications to guide medical management of patients with PAD.
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