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Cerecedo CD, Silva A, Alia VS, Vargas A, Garza A, El Shazly O, Candil AJ. Cilostazol after endovascular therapy for femoropopliteal peripheral arterial disease: A systematic review and meta-analysis. J Vasc Surg 2024:S0741-5214(24)01786-5. [PMID: 39208919 DOI: 10.1016/j.jvs.2024.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Revised: 08/03/2024] [Accepted: 08/18/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Endovascular therapy (ET) outcomes for femoropopliteal peripheral arterial disease (FP-PAD) remain suboptimal. Cilostazol therapy may improve patency rates and decrease major adverse limb events after ET for FP-PAD. Our goal was to analyze published studies evaluating the use of cilostazol after ET for FP-PAD. METHODS We searched MEDLINE, EMBASE, and CENTRAL for randomized and observational studies (OSs) evaluating cilostazol therapy after ET for FP-PAD. We only included OSs adjusting for confounding variables. We analyzed observational and randomized studies separately and explored heterogeneity by estimating an I2 statistic. A fixed-effects model was chosen if the I2 statistic was low. If the two-sided probability of observing the difference between groups under a true null hypothesis was <5%, we considered this difference statistically significant. RESULTS We screened 2171 studies and included 26 papers in our analysis (5 randomized controlled trials and 21 OSs). All randomized studies were open label. In randomized studies, the odds of restenosis were lower in patients treated with cilostazol (pooled odds ratio, 0.28; 95% confidence interval [CI], 0.18-0.43; P < .01; I2 = 0%). The odds of target lesion revascularization (TLR) were also lower in patients treated with cilostazol (pooled odds ratio, 0.35; 95% CI, 0.22-0.65; P < .01; I2 = 0%). In OSs, we also identified associations between peri-interventional treatment with cilostazol and lower rates of restenosis (pooled hazard ratio [pHR], 0.57; 95% CI, 0.51-0.65; P < .01; I2 = 34%), TLR (pHR, 0.53; 95% CI, 0.36-0.79; P < .01; I2 = 0%), and amputation (pHR, 0.54; 95% CI, 0.32-0.90; P = .02; I2 = 30%). CONCLUSIONS In randomized open-label studies, peri-interventional treatment with cilostazol after ET for FP-PAD decreased the odds of restenosis and TLR (Level 1A). Similarly, in OSs that adjusted for confounding, peri-interventional cilostazol therapy was associated with lower rates of restenosis, TLR, and amputation (Level 2A).
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Affiliation(s)
- Christian D Cerecedo
- Department of Surgery, University of Texas Rio Grande Valley School of Medicine, Harlingen, TX.
| | - Aaron Silva
- Department of Surgery, University of Texas Rio Grande Valley School of Medicine, Harlingen, TX
| | - Valentine S Alia
- Department of Surgery, University of Texas Rio Grande Valley School of Medicine, Harlingen, TX
| | - Ana Vargas
- Department of Surgery, University of Texas Rio Grande Valley School of Medicine, Harlingen, TX
| | - Alejandro Garza
- Department of Surgery, Doctor's Hospital at Renaissance, Edinburg, TX
| | - Omar El Shazly
- Department of Surgery, Medical College of Georgia at Augusta University, Augusta, GA
| | - Alejandro J Candil
- Department of Surgery, University of Texas Rio Grande Valley School of Medicine, Harlingen, TX
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2
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Laparra-Escareño H, Ortega-Gómez A, Zentella-Dehesa A, Manzo-Merino J, Vergara-Ascencio CA, Antuñano-Blanco MDC, Lopez-Santacruz JR, Montalvo-Jave EE, Anaya-Ayala JE, Lozano-Corona R, Hinojosa CA. The effect of cilostazol on the platelet-derived growth factor-beta/beta isoform reduction on venous hyperplasia in an experimental balloon-induced injury model. Vascular 2024; 32:842-849. [PMID: 36911886 DOI: 10.1177/17085381231162160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
BACKGROUND Intimal hyperplasia is the response to endothelial injury. Platelet-derived growth factor is released early and favors the formation of intimal hyperplasia. Although multiple treatments, from open surgery to endovascular techniques, have been used they remain controversial. There is currently interest in developing pharmacological strategies to address this pathology. Local vascular inflammation induced by vessel barotrauma generates intimal hyperplasia due to mechanical stress over the venous endothelium. Cilostazol is a selective phosphodiesterase type 3 (PDE3) selective inhibitor with a regulatory effect over intimal hyperplasia. The objective was to investigate cilostazol's role in inhibiting smooth muscle cell proliferation due to changes in the expression and release of PDGF-BB isoform and the effect on developing IH using an experimental model of vascular barotrauma (balloon-induced injury model). METHODS We included 12 New Zealand rabbits. The balloon-induced injury model (BIIM) and experimental group cilostazol (20 mg/kg/day) included 6 rabbits each. Contralateral veins from 6 rabbits used in BIIM model has been taken as control group. We measured and compared the expression of PDGF-BB and the development of IH. A pathologist board chooses a PDGFRα antibody to localized its expression by immunohistochemistry analysis. Subsequently, using an automated immunohistochemical staining machine, the PDGFR expression was evaluated using a Zeiss Primo Star 4 light microscope. RESULTS The measurement obtained in the intimal layer was: 126.12 μm2 in the CG, 232 μm2 in the BIIM group, and 178 μm2 in the EG. A statistically significant difference was observed. Baseline serum concentrations of PDGF-BB in the BIIM group were 0.22 pg/mL. At 12 h 0.42 pg/mL, and 0.17 pg/mL at seven days. In the experimental group, the basal levels were 0.33 pg/mL. With the use of cilostazol, a lower peak was obtained at 12 h (0.08 pg/mL). This difference was statistically significant. CONCLUSIONS Cilostazol induced a significant reduction of IH caused by barotrauma in the venous endothelium, which correlates with decrease in the PDGF-BB in serum. This could be attributed to the pharmacologic effect on PDGFR expression.
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MESH Headings
- Cilostazol/pharmacology
- Animals
- Hyperplasia
- Disease Models, Animal
- Rabbits
- Vascular System Injuries/pathology
- Vascular System Injuries/metabolism
- Vascular System Injuries/drug therapy
- Becaplermin/pharmacology
- Cell Proliferation/drug effects
- Neointima
- Phosphodiesterase 3 Inhibitors/pharmacology
- Muscle, Smooth, Vascular/drug effects
- Muscle, Smooth, Vascular/pathology
- Muscle, Smooth, Vascular/metabolism
- Male
- Veins/drug effects
- Veins/metabolism
- Veins/pathology
- Down-Regulation
- Myocytes, Smooth Muscle/drug effects
- Myocytes, Smooth Muscle/pathology
- Myocytes, Smooth Muscle/metabolism
- Angioplasty, Balloon/adverse effects
- Angioplasty, Balloon/instrumentation
- Protein Isoforms/metabolism
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Affiliation(s)
- Hugo Laparra-Escareño
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Ciudad de Mexico, Mexico
| | - Alette Ortega-Gómez
- Laboratory of Translational Medicine, National Institute of Cancerology, Ciudad de Mexico, Mexico
| | - Alejandro Zentella-Dehesa
- Department of Biochemistry, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Ciudad de Mexico, Mexico
| | | | - Carlos Acxel Vergara-Ascencio
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Ciudad de Mexico, Mexico
| | | | - Jose Roberto Lopez-Santacruz
- School of Veterinary Medicine an Animal Husbandry and Pathology, Universidad Nacional Autonoma de Mexico, Ciudad de Mexico, Mexico
| | | | - Javier E Anaya-Ayala
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Ciudad de Mexico, Mexico
| | - Rodrigo Lozano-Corona
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Ciudad de Mexico, Mexico
| | - Carlos A Hinojosa
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Ciudad de Mexico, Mexico
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3
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Kapur V. Antithrombotic Strategies in Endovascular Interventions. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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4
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Qin Y, Shi Y, Zhuo H, Yu T, Wang W, Li X, Da L, Ran F. Short-term efficacy and safety of TurboHawk atherectomy for in-stent restenosis in peripheral artery disease: a single-centre experience. ANZ J Surg 2022; 92:448-452. [PMID: 35040546 DOI: 10.1111/ans.16551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 11/05/2020] [Accepted: 12/17/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Information regarding the efficacy of the TurboHawk atherectomy for the treatment of in-stent restenosis (ISR) in patients with peripheral artery disease (PAD) of the lower extremity is scarce. This study was performed to investigate the curative efficacy and safety of the TurboHawk system for ISR in PAD patients over 60 years old. METHODS The TurboHawk atherectomy device was used to treat ISR in 28 patients with PAD. The intraoperative, 2-day postoperative, 3-month, and 2-year follow-up data were obtained. Differences in the ankle-brachial index (ABI), Rutherford class and minimum diameter of the femoral-popliteal artery were analysed along with the correlations of the factors associated with patency. RESULTS Twenty-six patients (92.86%) had successful surgeries. All patients reported alleviation of pain and intermittent claudication after surgery. One patient who had a malignant hepatoma and coronary heart disease received an amputation on the 76th postoperative day and another patient who had atrial fibrillation received a thrombectomy on the 40th postoperative day. TurboHawk atherectomy increased the ABI (from 0.30 to 0.70, P < 0.0001) and minimum diameter (from 0 to 4.93 mm, P < 0.0001) and reduced the Rutherford class (from 4.00 to 2.00, P < 0.0001). During the 3-month follow-up, the median minimum diameter, ABI, and Rutherford class were 4.12, 0.69, and 2.00, respectively. No death happened during the 3-month follow-up. CONCLUSIONS The TurboHawk atherectomy is a safe and effective technique for ISR in PAD patients over 60 years old.
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Affiliation(s)
- Yi Qin
- Department of Vascular Surgery, Nanjing Drum-Tower Hospital, Affiliated to Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Yan Shi
- Department of Vascular Surgery, Nanjing Drum-Tower Hospital, Affiliated to Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Huawei Zhuo
- Department of Vascular Surgery, Nanjing Drum-Tower Hospital, Affiliated to Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Tong Yu
- Department of Vascular Surgery, Nanjing Drum-Tower Hospital, Affiliated to Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Wei Wang
- Department of Vascular Surgery, Nanjing Drum-Tower Hospital, Affiliated to Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Xiaoqiang Li
- Department of Vascular Surgery, Nanjing Drum-Tower Hospital, Affiliated to Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Lun Da
- Nanjing Prevention and Treatment Center for Occupational Disease, Nanjing, Jiangsu, China
| | - Feng Ran
- Department of Vascular Surgery, Nanjing Drum-Tower Hospital, Affiliated to Nanjing University Medical School, Nanjing, Jiangsu, China
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de Donato G, Setacci F, Mele M, Giannace G, Galzerano G, Setacci C. Restenosis after Coronary and Peripheral Intervention: Efficacy and Clinical Impact of Cilostazol. Ann Vasc Surg 2017; 41:300-307. [PMID: 28242395 DOI: 10.1016/j.avsg.2016.08.050] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 08/26/2016] [Accepted: 08/26/2016] [Indexed: 11/16/2022]
Abstract
Restenosis is one of the main complications in patients undergoing coronary or peripheral revascularization procedures and is the leading cause for their long-term failures. Cilostazol is the only pharmacotherapy that showed an adequate efficacy for preventing restenosis in randomized, controlled studies after coronary or peripheral revascularization procedures. The present review sums up the main clinical evidence supporting the use of cilostazol after revascularization interventions, focusing on all its benefits, warnings, and administration schedules.
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Affiliation(s)
- Gianmarco de Donato
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy.
| | | | - Mariagnese Mele
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Giovanni Giannace
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Giuseppe Galzerano
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Carlo Setacci
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
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6
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Shishehbor MH. Antithrombotic Strategies in Endovascular Interventions. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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7
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Mitsuoka H, Nakai M, Terai Y, Gotou S, Miyano Y, Tsuchiya K, Yamazaki F. Retrograde Stent Placement for Symptomatic Spontaneous Isolated Dissection of the Superior Mesenteric Artery. Ann Vasc Surg 2016; 35:203.e17-21. [DOI: 10.1016/j.avsg.2016.01.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 11/10/2015] [Accepted: 01/16/2016] [Indexed: 11/25/2022]
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8
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Rogers KC, Oliphant CS, Finks SW. Clinical efficacy and safety of cilostazol: a critical review of the literature. Drugs 2016; 75:377-95. [PMID: 25758742 DOI: 10.1007/s40265-015-0364-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Cilostazol is a unique antiplatelet agent that has been commercially available for over two decades. As a phosphodiesterase III inhibitor, it reversibly inhibits platelet aggregation yet also possesses vasodilatory and antiproliferative properties. It has been widely studied in a variety of disease states, including peripheral arterial disease, cerebrovascular disease, and coronary artery disease with percutaneous coronary intervention. Overall, cilostazol appears to be a promising agent in the management of these disease states with a bleeding profile comparable to placebo; even when combined with other antiplatelet agents, cilostazol does not appear to increase the rate of bleeding. Despite the possible benefit of cilostazol, its use is limited by tolerability as some patients often report drug discontinuation due to headache, diarrhea, dizziness, or increased heart rate. To date, it has been predominantly studied in the Asian population, making it difficult to extrapolate these results to a more diverse patient population. This paper discusses the evolving role of cilostazol in the treatment of vascular diseases.
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Affiliation(s)
- Kelly C Rogers
- Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, 881 Madison Ave, Rm 457, Memphis, TN, 38163, USA,
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9
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Iftikhar O, Oliveros K, Tafur AJ, Casanegra AI. Prevention of Femoropopliteal In-Stent Restenosis With Cilostazol. Angiology 2015; 67:549-55. [DOI: 10.1177/0003319715604768] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Severe peripheral artery disease requires revascularization to relieve life-limiting ischemic symptoms. Postrevascularization in-stent restenosis continues to be a problem after femoropopliteal procedures. Our aim was to evaluate the use of cilostazol to prevent in-stent restenosis among patients with lower extremity arterial stenting. We performed a MEDLINE and EMBASE search and reviewed the abstracts and manuscripts following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The primary efficacy outcome was patency rate after stenting. The odds ratio estimates were pooled using the Mantel–Haenszel random-effects method. We identified 524 studies, and 20 articles were fully abstracted and 4 were included in the meta-analysis. The total number of patients included was 2434. Patients in the cilostazol group had better primary patency rates after endovascular stenting than those not taking cilostazol (odds ratio: 0.55; 95% confidence interval: 0.43-0.71). The use of cilostazol appears to prevent in-stent restenosis of high-risk patients.
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Affiliation(s)
- Omer Iftikhar
- Department of Internal Medicine, University of Oklahoma Health Sciences Center and Department of Veterans Affairs Medical Center, Oklahoma City, OK, USA
| | - Karla Oliveros
- Universidad Católica de Santiago de Guayaquil, Guayaquil, Ecuador
| | - Alfonso J. Tafur
- Vascular Medicine, Cardiovascular Institute, NorthShore University HealthSystem, Evanston, IL, USA
| | - Ana I. Casanegra
- Cardiovascular Medicine Section, Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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10
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Warner CJ, Greaves SW, Larson RJ, Stone DH, Powell RJ, Walsh DB, Goodney PP. Cilostazol is associated with improved outcomes after peripheral endovascular interventions. J Vasc Surg 2014; 59:1607-14. [PMID: 24468286 DOI: 10.1016/j.jvs.2013.11.096] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 11/22/2013] [Accepted: 11/30/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Although cilostazol is commonly used as an adjunct after peripheral vascular interventions, its efficacy remains uncertain. We assessed the effect of cilostazol on outcomes after peripheral vascular interventions using meta-analytic techniques. METHODS We searched MEDLINE (1946-2012), Cochrane CENTRAL (1996-2012), and trial registries for studies comparing cilostazol in combination with antiplatelet therapy to antiplatelet therapy alone after peripheral vascular interventions. Treatment effects were reported as pooled risk/hazard ratio (HR) with random-effects models. RESULTS Two randomized trials and four retrospective cohorts involving 1522 patients met inclusion criteria. Across studies, mean age ranged from 65 to 76 years, and the majority of patients were male (64%-83%); mean follow-up ranged from 18 to 37 months. Most interventions were in the femoropopliteal segment, and overall, 68% of patients had stents placed. Pooled estimates demonstrated that the addition of cilostazol was associated with decreased restenosis (relative risk [RR], 0.71; 95% confidence interval [CI], 0.60-0.84; P < .001), improved amputation-free survival (HR, 0.63; 95% CI, 0.47-0.85; P = .002), improved limb salvage (HR, 0.42; 95% CI, 0.27-0.66; P < .001), and improved freedom from target lesion revascularization (RR, 1.36; 95% CI, 1.14-1.61; P < .001). There was no significant reduction in mortality among those receiving cilostazol (RR, 0.73; 95% CI, 0.45-1.19; P = .21). CONCLUSIONS The addition of cilostazol to antiplatelet therapy after peripheral vascular interventions is associated with a reduced risk of restenosis, amputation, and target lesion revascularization in our meta-analysis of six studies. Consideration of cilostazol as a medical adjunct after peripheral vascular interventions is warranted, presuming these findings are broadly generalizable.
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Affiliation(s)
- Courtney J Warner
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | - Spencer W Greaves
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - Robin J Larson
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH
| | - David H Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Richard J Powell
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Daniel B Walsh
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Shishehbor MH, Katzen BT. Antithrombotic Strategies in Endovascular Interventions: Current Status and Future Directions. Interv Cardiol Clin 2013; 2:627-633. [PMID: 28582189 DOI: 10.1016/j.iccl.2013.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Despite increasing numbers of endovascular interventions to treat arterial and venous disease, scant level 1 evidence is available regarding the role of antithrombotic and antiplatelet therapy in patients undergoing these procedures. The current practice in this regard is heterogeneous and has mainly been driven by data from coronary artery disease and percutaneous coronary intervention. This article discusses the role of antithrombotic and antiplatelet agents for endovascular intervention.
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Affiliation(s)
- Mehdi H Shishehbor
- Endovascular Services, Heart & Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, J3-05, Cleveland, OH 44195, USA.
| | - Barry T Katzen
- Baptist Cardiac & Vascular Institute, 8900 North Kendall Drive, Miami, FL 33176, USA
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