Lack of Evidence for Dual Antiplatelet Therapy after Endovascular Arterial Procedures: A Meta-analysis. Eur J Vasc Endovasc Surg. 2016;52:253-262. [PMID: 27241270 DOI: 10.1016/j.ejvs.2016.04.023]

Practice Patterns of Antiplatelet and Anticoagulant Therapy After Fenestrated/Branched Endovascular Aortic Repair

OBJECTIVE

Antiplatelet and/or anticoagulant therapy are commonly prescribed after fenestrated/branched endovascular aortic repair (F/BEVAR). However, the optimal regimen remains unknown. We sought to characterize practice patterns and outcomes of antiplatelet and anticoagulant use in patients who underwent F/BEVAR.

METHODS

Consecutive patients enrolled (2012-2023) as part of the United States Aortic Research Consortium (US-ARC) from ten independent physician-sponsored investigational device exemption (PS-IDE) studies were evaluated. The cohort was characterized by medication regimen on discharge from index F/BEVAR: 1. Aspirin alone OR p2y12 alone (single-antiplatelet therapy, SAPT), 2. Anticoagulant Alone, 3. Aspirin+p2y12 (dual-antiplatelet therapy, DAPT), 4. Aspirin+anticoagulant OR p2y12+anticoagulant (SAPT+Anticoagulant), 5. Aspirin+p2y12+anticoagulant (triple therapy, TT), and 6. No Therapy. Kaplan-Meier analysis and Cox proportional hazards modeling were used to compare 1-year outcomes including survival, target artery patency, freedom from bleeding complication, freedom from all reinterventions, and freedom from stent-specific reintervention.

RESULTS

Of the 1525 patients with complete exposure and outcome data, 49.6% were discharged on DAPT, 28.8% on SAPT, 13.6% on SAPT+Anticoagulant, 3.2% on TT, 2.6% on Anticoagulant Alone, and 2.2% on No Therapy. Discharge medication regimen was not associated with differences in 1-year survival, bleeding complications, composite reintervention rate, or stent-specific reintervention rate. However, there was a significant difference in 1-year target artery patency. On multivariable analysis comparing to SAPT, DAPT conferred a lower hazard of loss of target artery patency (HR 0.48, 95% CI 0.27-0.84, p=0.01). On sub-analyses of renal stents alone or visceral stents alone, DAPT no longer had a significantly lower hazard of loss of target artery patency (Renal: HR 0.66, 95% CI 0.35-1.27, p=0.22. Visceral: HR 0.31, 95% 0.05-1.9, p=0.21). Lastly, duration of DAPT therapy (1 month, 6 months, or 1 year) did not significantly affect target artery patency.

CONCLUSIONS

Practice patterns for antiplatelet and anticoagulant regimens after F/BEVAR vary widely across the US-ARC. There were no differences in bleeding complications, survival or reintervention rates among different regimens, but higher branch vessel patency was noted in the DAPT cohort. These data suggest there is a benefit in DAPT therapy. However, the generalizability of this finding is limited by the retrospective nature of this data, and the clinical significance of this finding is unclear, as there is no difference in survival, bleeding, or reintervention rates amongst the different regimens. Hence, an "optimal" regimen, including the duration of such regimen, could not be clearly discerned. This suggests equipoise for a randomized trial, nested within this cohort, to identify the most effective antiplatelet/anticoagulant regimen for the growing number of patients being treated globally with F/BEVAR.

Revascularization Strategies for Acute and Chronic Mesenteric Ischemia: A Narrative Review

Mesenteric ischemia is a challenging condition characterized by insufficient blood perfusion to the mesentery and, consequently, intestinal tissues that continues to perplex clinicians. Despite its low prevalence, the condition's variable clinical presentation and elusive radiographic diagnosis can delay life-saving interventions in the acute setting and deteriorate the quality of life of patients when left undiagnosed or misdiagnosed.

PURPOSE

Review and summarize recent diagnostic updates and emergent intervention strategies for acute and chronic mesenteric ischemia.

METHODS

A narrative review of all relevant studies from January 2022 through September 2023.

RESULTS

A total of 11 studies from MEDLINE, supplemented with 44 studies from Google Scholar, were included in the review.

CONCLUSIONS

Both acute and chronic mesenteric ischemia propose diagnostic and therapeutic challenges for interventionalists. Computed tomographic angiography remains the diagnostic modality of choice for both. Open surgical intervention remains the gold standard for acute mesenteric ischemia, while endovascular techniques are preferred for chronic mesenteric ischemia.

Management of patients with chronic mesenteric ischemia across three consecutive eras

BACKGROUND

Endovascular intervention (EI) is the most commonly used modality for chronic mesenteric ischemia (CMI). Since the inception of this technique, numerous publications have reported the associated clinical outcomes. However, no publication has reported the comparative outcomes over a period of time in which both the stent platform and adjunctive medical therapy have evolved. This study aims to assess the impact of the concomitant evolution of both the endovascular approach and optimal guideline-directed medical therapy (GDMT) on CMI outcomes over three consecutive time eras.

METHODS

A retrospective review at a quaternary center from January 2003 to August 2020 was performed to identify patients who underwent EIs for CMI. The patients were divided into three groups based on the date of intervention: early (2003-2009), mid (2010-2014), and late (2015-2020). At least one angioplasty/stent was performed for the superior mesenteric artery (SMA) and/or celiac artery. The patients' short- and mid-term outcomes were compared between the groups. Univariable and multivariable Cox proportional hazard models were also conducted to evaluate the clinical predictors for primary patency loss in SMA only subgroup.

RESULTS

A total of 278 patients were included (early, 74; mid, 95; late, 109). The overall mean age was 71 years, and 70% were females. High technical success (early, 98.6%; mid, 100%; late, 100%; P = .27) and immediate resolution of symptoms (early, 86.3%; mid, 93.7%; late, 90.8%; P = .27) were noted over the three eras. In both the celiac artery and SMA cohorts, the use of bare metal stents (BMS) declined over time (early, 99.0%; mid, 90.3%; late, 65.5%; P < .001) with a proportionate increase in covered stents (CS) (early, 0.99%; mid, 9.7%; late, 28.9%; P < .001). The use of postoperative antiplatelet and statins has increased over time (early, 89.2%; mid, 97.9%; late, 99.1%; P = .003) and (early, 47%; mid, 68%; late, 81%; P = .001), respectively. In the SMA stent-only cohort, no significant differences were noted in primary patency rates between BMS and CS (hazard ratio, 0.95; 95% confidence interval, 0.26-2.87; P = .94). High-intensity preoperative statins were associated with fewer primary patency loss events compared to none/low- or moderate-intensity statins (hazard ratio, 0.30; 95% confidence interval, 0.11-0.72; P = .014).

CONCLUSIONS

Consistent outcomes were observed for CMI EIs across three consecutive eras. In the SMA stent-only cohort, no statistically significant difference in early primary patency was noted for CS and BMS, making the use of CS at additional cost controversial and possibly not cost effective. Notably, the preoperative high-intensity statins were associated with improved SMA primary patency. These findings demonstrate the importance of guideline-directed medical therapy as an essential adjunct to EI in the treatment of CMI.

Dual antiplatelet management in the perioperative period: updated and expanded systematic review

BACKGROUND

Antiplatelet agents are central in the management of vascular disease. The use of dual antiplatelet therapy (DAPT) for the management of thromboembolic complications must be weighed against bleeding risk in the perioperative setting. This balance is critical in patients undergoing cardiac or non-cardiac surgery. The management of patients on DAPT for any indication (including stents) is not clear and there is limited evidence to guide decision-making. This review summarizes current evidence since 2015 regarding the occurrence of major adverse events associated with continuing, suspending, or varying DAPT in the perioperative period.

METHODS

A research librarian searched PubMed and Cochrane from November 30, 2015 to May 17, 2022, for relevant terms regarding adult patients on DAPT for any reason undergoing surgery, with a perioperative variation in DAPT strategy. Outcomes of interest included the occurrence of major adverse cardiac events, major adverse limb events, all-cause death, major bleeding, and reoperation. We considered withdrawal or discontinuation of DAPT as stopping either aspirin or a P2Y12 inhibitor or both agents; continuation of DAPT indicates that both drugs were given in the specified timeframe.

RESULTS

Eighteen observational studies met the inclusion criteria. No RCTs were identified, and no studies were judged to be at low risk of bias. Twelve studies reported on CABG. Withholding DAPT therapy for more than 2 days was associated with less blood loss and a slight trend favoring less transfusion and surgical re-exploration. Among five observational CABG studies, there were no statistically significant differences in patient death across DAPT management strategies. Few studies reported cardiac outcomes. The remaining studies, which were about procedures other than exclusively CABG, demonstrated mixed findings with respect to DAPT strategy, bleeding, and ischemic outcomes.

CONCLUSION

The evidence base on the benefits and risks of different perioperative DAPT strategies for patients with stents is extremely limited. The strongest signal, which was still judged as low certainty evidence, is that suspension of DAPT for greater than 2 days prior to CABG surgery is associated with less bleeding, transfusions, and re-explorations. Different DAPT strategies' association with other outcomes of interest, such as MACE, remains uncertain.

SYSTEMATIC REVIEW REGISTRATION

A preregistered protocol for this review can be found on the PROSPERO International Prospective Register of systematic reviews ( http://www.crd.york.ac.uk/PROSPERO/ ; registration number: CRD42022371032).

Dual Antiplatelet Alternatives are Associated With Increased Stroke and Death After Transcarotid Revascularization

OBJECTIVE

To define the risks associated with the replacement of dual antiplatelets for alternate medication regimens.

BACKGROUND

Patients undergoing transcarotid artery revascularization (TCAR) for atherosclerotic disease in the Vascular Quality Initiative database from September 2016 to June 2022 were included. In all, 29,802 TCAR procedures were captured between 2016 and 2022, consisting of 24,651 (82.7%) maintained on dual antiplatelet therapy (DAPT) and 5151 (17.3%) on alternative regimens.

METHODS

Patients maintained on DAPT were compared with those on alternative regimens consisting of any combination of single antiplatelet monotherapy and/or anticoagulation.

RESULTS

On univariable analysis, patients on alternative medications were more likely to experience in-hospital death, ipsilateral stroke, any stroke, and transient ischemic attacks compared with patients in the DAPT group. The mortality rate was higher at 1 year in the alternative cohort (4.7% vs 7.0%, P <0.01). The use of alternate medication regimens was associated with increased odds of stroke and the composite outcome of in-hospital stroke/death compared with DAPT. There was also a significant association between alternative medication use and increased odds of in-hospital transient ischemic attack, immediate stent occlusion, and return to the operating room. At 1 year, there was no significant difference in the incidence of stroke between the 2 groups. However, the use of alternate regimens was associated with higher 1-year of mortality after multivariable adjustment.

CONCLUSIONS

Patients not maintained on DAPT after TCAR experienced an increased risk of stroke and death in the perioperative and follow-up periods. Increased surgeon vigilance is required to ensure compliance with dual antiplatelets as recommended.

Anticoagulation and Antiplatelet Agents in Peripheral Arterial Interventions

Effective revascularization of peripheral artery disease relies on periprocedural pharmacological regulation of the clotting cascade. Patient-specific factors such as cardiovascular risk factors, contraindications, and individual psychosocial factors must be considered when initiating post revascularization management. Management with anticoagulant and antiplatelet agents is discussed to guide the interventionalist on which therapy may be appropriate for their patient. While exact treatment may be institution and provider dependent, the interventionist must be familiar with the available classes of medications and how they can be prescribed in the postprocedural setting to improve cardiovascular outcomes.

Safety of Transcarotid Revascularization in Patients with a Contraindication to Dual Antiplatelets

OBJECTIVE

Current carotid artery stenting practice guidelines recommend dual antiplatelets to reduce major adverse cardiovascular events during and after transcarotid revascularization (TCAR). However, some patients are poor candidates for this regimen, due to preexisting need for anticoagulation, allergies, and/or risk of major bleeding. Therefore, this investigation was performed to review outcomes associated with patients undergoing TCAR while on alternative medication regimens to determine safety and efficacy.

METHODS

A retrospective review was performed of a combined database created by the combination of institutional carotid revascularization archives maintained at 2 high-volume TCAR health systems. Patients taking dual antiplatelets were compared to those on nontraditional medications with respect to demographics and perioperative and long-term outcomes.

RESULTS

Between our 2 member institutions, 729 TCAR procedures, consisting of 549 patients on dual antiplatelets and 180 on alternative treatments, qualified for study inclusion and analyzed. The cohort not taking dual antiplatelets presented with a heavier comorbidity burden by Charlson Comorbidity Index (5.3 ± 2.2 vs 6.1 ± 2.2, P < .01). Additionally, these patients underwent higher risk revascularization procedures, as they had a higher proportion of symptomatic lesions (34.6% vs 43.0%, P = .03). Despite these deviations in baseline characteristics, similar outcomes between groups were observed in the 30-day perioperative period with respect to stroke (2.2% vs 2.8%, P = .58), death (1.3% vs 1.1%, P > .99), and myocardial infarction (.4% vs 0%, P > .99). Similarly, rates of reintervention (1.6% vs 1.1%, P > .99), hematoma formation (2.4% vs 2.2%, P > .99), and stent thrombosis (.5% vs .6%, P > .99) were consistent, regardless of antiplatelet status. At follow-up of 25.4 and 29.1 months, respectively, for the dual antiplatelet and alternative treatment cohorts, no deviations with respect to reintervention, stroke, myocardial infarction, or stent thrombosis were noted. However, there was an increased risk of death (5.4% vs 13.5%, P = .02) in the alternative regimen group.

CONCLUSION

In this small series of TCARs, patients not maintained on dual antiplatelets did not experience more perioperative adverse events after TCAR. However, more studies, in larger series, are required to verify and validate these findings.

Antithrombotic Treatment in Lower Extremity Peripheral Arterial Disease

Lower extremity arteries might be affected by atherosclerotic peripheral arterial disease (PAD), or by embolization causing ischaemic symptoms. Patients with PAD often have widespread atherosclerosis, and progression of PAD is associated with increased risk for both other cardiovascular events and cardiovascular mortality. Peripheral arterial disease patients should therefore be offered both non-pharmacological and pharmacological secondary prevention to reduce the risk for future ischemic arterial complications. This review is focussed on the rationale for recommendations on antiplatelet and anticoagulant treatment in PAD. Asymptomatic PAD does not warrant either anticoagulant or antiplatelet treatment, whereas patients with ischaemic lower extremity symptoms such as intermittent claudication or critical limb ischemia caused by atherosclerosis should be offered platelet antiaggregation with either low dose aspirin or clopidogrel. Combined treatment with aspirin and low-dose of the direct oral anticoagulant (DOAC) rivaroxaban should be considered and weighed against bleeding risk in symptomatic PAD patients considered at high risk for recurrent ischaemic events and in patients having undergone endovascular or open surgical intervention for PAD. Patiens with cardiogenic embolization to lower extremity arteries should be recommended anticoagulant treatment with either one of the DOACs (apixaban, dabigatran, edoxaban, and rivaroxaban) or warfarin.

The challenge of choosing in cardiovascular risk management

Cardiovascular disease (CVD) is a major cause of morbidity and mortality worldwide. For many years guidelines have listed optimal preventive therapy. More recently, novel therapeutic options have broadened the options for state-of-the-art CV risk management (CVRM). In the majority of patients with CVD, risk lowering can be achieved by utilising standard preventive medication combined with lifestyle modifications. In a minority of patients, add-on therapies should be considered to further reduce the large residual CV risk. However, the choice of which drug combination to prescribe and in which patients has become increasingly complicated, and is dependent on both the absolute CV risk and the reason for the high risk. In this review, we discuss therapeutic decisions in CVRM, focusing on (1) the absolute CV risk of the patient and (2) the pros and cons of novel treatment options.

Successful Endovascular and Endoscopic Treatment of a Symptomatic Celiac Artery Aneurysm for Obstructive Jaundice: A Clinical Case Report

BACKGROUND

Celiac artery aneurysm (CAA) is an infrequent aneurysm of the celiac visceral branch and is potentially life-threatening, mainly due to the risk of rupture. CAA is often diagnosed following rupture and rarely diagnosed secondary to a primary manifestation; obstructive jaundice is extremely rare and poorly described. This clinical case report reports a combined endovascular and endoscopic noninvasive treatment.

METHODS

A 51-year old male was admitted to the emergency department at the Arcispedale Santa Maria Nuova in Reggio Emilia following several days of jaundice. The patient did not have any history of abdominal trauma, chronic pancreatitis, bile duct calculus or alcohol abuse. Cholestatic impairment was demonstrated by blood analyses and abdominal ultrasound revealed a large cephalo-pancreatic mass. Contrast-enhanced computed tomography (CT) showed a 40 mm CAA, causing a common bile duct (CBD) compression and dilatation of the hepatic bile ducts. After a multidisciplinary team consultation, a noninvasive, combined endovascular and endoscopic approach was programmed in a hybrid room.

RESULTS

Immediate results confirmed successful exclusion of the CAA, stent graft patency and the absence of endoleak with correct positioning of a plastic stent in the CBD. At 1 month, an abdominal CT-angiography (CTA) evidenced a type II endoleak, successfully treated with an endovascular secondary procedure and an asymptomatic, partial downward dislodgement of the plastic stent in the CBD was correct with the positioning of 2 plastic stents. At 3-months cholangiography showed no dilation of intraepatic biliary ducts.

CONCLUSIONS

Symptomatic CAA with common bile duct compression could be amenable to a combined endovascular and endoscopic noninvasive treatment.

Platelet aggregation inhibitor prescription for newly diagnosed peripheral arterial disease in the Netherlands: a cohort study

OBJECTIVES

Pharmacological treatment of peripheral arterial disease (PAD) comprises of antiplatelet therapy (APT), blood pressure control and cholesterol optimisation. Guidelines provide class-I recommendations on the prescription, but there are little data on the actual prescription practices. Our study provides insight into the prescription of medication among patients with PAD in the Netherlands and reports a 'real-world' patient journey through primary and secondary care.

DESIGN

We conducted a cohort study among patients newly diagnosed with PAD between 2010 and 2014.

SETTING

Data were obtained from the PHARMO Database Network, a population-based network of electronic pharmacy, primary and secondary healthcare setting records in the Netherlands. The source population for this study comprised almost 1 million individuals.

PARTICIPANTS

'Newly diagnosed' was defined as a recorded International Classification of Primary Care code for PAD, a PAD-specific WCIA examination code or a diagnosis recorded as free text episode in the general practitioner records with no previous PAD diagnosis record and no prescription of P2Y12 inhibitors or aspirin the preceding year. The patient journey was defined by at least 1 year of database history and follow-up relative to the index date.

RESULTS

Between 2010 and 2014, we identified 3677 newly diagnosed patients with PAD. Most patients (91%) were diagnosed in primary care. Almost half of all patients (49%) had no APT dispensing record. Within this group, 33% received other anticoagulant therapy (vitamin K antagonist or direct oral anticoagulant). Mono-APT was dispensed as aspirin (40% of patients) or P2Y12 inhibitors (2.5% of patients). Dual APT combining aspirin with a P2Y12 inhibitor was dispensed to 8.5% of the study population.

CONCLUSION

Half of all patients with newly diagnosed PAD are not treated conforming to (international) guideline recommendations on thromboembolism prevention through APT. At least 33% of all patients with newly diagnosed PAD do not receive any antithrombotic therapy. Evaluation and improvement of APT prescription and thereby improved prevention of (secondary) cardiovascular events is warranted.

Treatment of the extracranial carotid artery in tandem lesions during endovascular treatment of acute ischemic stroke: a systematic review and meta-analysis

Endovascular treatment (EVT) is the standard treatment for patients with an acute ischemic stroke due to occlusion of large vessel occlusion (LVO). In 20% of patients, concomitant extracranial internal carotid artery (EICA) lesion is present. These tandem lesions (TL) offer a technical challenge. The treatment strategy for the treatment of the ipsilateral EICA is unclear. The aim of this review is to compare two treatment strategies for TL during EVT: balloon angioplasty (BA) only and immediate carotid artery stenting (iCAS). A systematic review and meta-analysis was performed. Data for each included study was extracted. For comparative studies a meta-analysis was performed. Functional outcome was expressed with the modified Rankin scale and safety endpoints were mortality and symptomatic intracranial hemorrhage (sICH). A total of 72 full text articles evaluating treatment of TL during EVT were screened. Sixteen iCAS and five comparative studies were included for meta-analysis. 53% of patients undergoing iCAS during EVT had good functional outcome in comparison to 45% of patients who underwent only BA. Mortality was comparable at 16% for both groups. The incidences of sICH were 8% and 4% for iCAS and BA respectively. In the meta-analysis, iCAS was associated with good functional outcome, with no significant differences in mortality and sICH with compared to BA. This study shows that treatment with iCAS of a simultaneously ipsilateral EICA lesion during EVT is associated with a favorable functional outcome compared to BA only with no significant difference in mortality or sICH. No conclusion could be drawn about the intracranial or extracranial first approach due to scarce of data. More studies are needed to determine long-term neurological outcomes, the necessity of re-interventions and optimal technical approach (intracranial or extracranial first).

Chronic mesenteric ischemia: Clinical practice guidelines from the Society for Vascular Surgery

BACKGROUND

Chronic mesenteric ischemia (CMI) results from the inability to achieve adequate postprandial intestinal blood flow, usually from atherosclerotic occlusive disease at the origins of the mesenteric vessels. Patients typically present with postprandial pain, food fear, and weight loss, although they can present with acute mesenteric ischemia and bowel infarction. The diagnosis requires a combination of the appropriate clinical symptoms and significant mesenteric artery occlusive disease, although it is often delayed given the spectrum of gastrointestinal disorders associated with abdominal pain and weight loss. The treatment goals include relieving the presenting symptoms, preventing progression to acute mesenteric ischemia, and improving overall quality of life. These practice guidelines were developed to provide the best possible evidence for the diagnosis and treatment of patients with CMI from atherosclerosis.

METHODS

The Society for Vascular Surgery established a committee composed of vascular surgeons and individuals experienced with evidence-based reviews. The committee focused on six specific areas, including the diagnostic evaluation, indications for treatment, choice of treatment, perioperative evaluation, endovascular/open revascularization, and surveillance/remediation. A formal systematic review was performed by the evidence team to identify the optimal technique for revascularization. Specific practice recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation system based on review of literature, the strength of the data, and consensus.

RESULTS

Patients with symptoms consistent with CMI should undergo an expedited workup, including a computed tomography arteriogram, to exclude other potential causes. The diagnosis is supported by significant arterial occlusive disease in the mesenteric vessels, particularly the superior mesenteric artery. Treatment requires revascularization with the primary target being the superior mesenteric artery. Endovascular revascularization with a balloon-expandable covered intraluminal stent is the recommended initial treatment with open repair reserved for select younger patients and those who are not endovascular candidates. Long-term follow-up and surveillance are recommended after revascularization and for asymptomatic patients with severe mesenteric occlusive disease. Patient with recurrent symptoms after revascularization owing to recurrent stenoses should be treated with an endovascular-first approach, similar to the de novo lesion.

CONCLUSIONS

These practice guidelines were developed based on the best available evidence. They should help to optimize the care of patients with CMI. Multiple areas for future research were identified.

Short-Term Clinical Outcomes of Single Versus Dual Antiplatelet Therapy after Infrainguinal Endovascular Treatment for Peripheral Arterial Disease

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.

Antiplatelet and anticoagulation therapy after revascularization for lower extremity artery disease: a national survey and literature overview

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.

Umbrella review and meta-analysis of antiplatelet therapy for peripheral artery disease

Background

The literature on antiplatelet therapy for peripheral artery disease has historically been summarized inconsistently, leading to conflict between international guidelines. An umbrella review and meta-analysis was performed to summarize the literature, allow assessment of competing safety risks and clinical benefits, and identify weak areas for future research.

Methods

MEDLINE, Embase, DARE, PROSPERO and Cochrane databases were searched from inception until January 2019. All meta-analyses of antiplatelet therapy in peripheral artery disease were included. Quality was assessed using AMSTAR scores, and GRADE analysis was used to quantify the strength of evidence. Data were pooled using random-effects models.

Results

Twenty-eight meta-analyses were included. Thirty-three clinical outcomes and 41 antiplatelet comparisons in 72 181 patients were analysed. High-quality evidence showed that antiplatelet monotherapy reduced non-fatal strokes (3 (95 per cent c.i. 0 to 6) fewer per 1000 patients), In symptomatic patients, it reduced cardiovascular deaths (8 (0 to 16) fewer per 1000 patients), but increased the risk of major bleeding (7 (3 to 14) more events per 1000). In asymptomatic patients, monotherapy reduced non-fatal strokes (5 (0 to 8) fewer per 1000), but had no other clinical benefit. Dual antiplatelet therapy caused more major bleeding after intervention than monotherapy (37 (8 to 102) more events per 1000), with very low-quality evidence of improved endovascular patency (risk ratio 4·00, 95 per cent c.i. 0·91 to 17·68).

Conclusion

Antiplatelet monotherapy has minimal clinical benefit for asymptomatic peripheral artery disease, and limited benefit for symptomatic disease, with a clear risk of major bleeding. There is a lack of evidence to guide antiplatelet prescribing after peripheral endovascular intervention.

Atheroma of the Innominate Artery Presenting as a Transient Ischemic Attack

Supra-aortic atherosclerotic lesions, including innominate artery atheromas, are an uncommon but established cause of transient ischemic attacks, stroke, upper extremity ischemia, and vertebrobasilar insufficiency.

We present a patient with a transient ischemic attack admitted with right hemispheric symptoms who was found to have a severe ulcerated innominate artery atheroma. The patient underwent an aortic arch angiogram with stenting of the innominate artery.

The proper diagnosis, treatment, and management of innominate artery atheromas are imperative to prevent further cardiovascular morbidity and mortality in patients. Currently, both endovascular and surgical options are available for revascularization, and there have been no randomized controlled trials comparing endovascular versus open repair to standardize one as the standard of care over the other. No randomized controlled trials are examining the benefit of dual versus single antiplatelet therapy post-stenting in supra-aortic atherosclerotic lesions. We believe that this topic warrants further research and needs evidence-based guidelines to help direct physicians about treatment and management.

On-Treatment Platelet Reactivity is a Predictor of Adverse Events in Peripheral Artery Disease Patients Undergoing Percutaneous Angioplasty

OBJECTIVES

Few data are available on the association between a different entity of platelet inhibition on antiplatelet treatment and clinical outcomes in patients with peripheral artery disease (PAD). The aim of this study was to evaluate the degree of on-treatment platelet reactivity, and its association with ischaemic and haemorrhagic adverse events at follow up in PAD patients undergoing percutaneous transluminal angioplasty (PTA).

METHODS

In this observational, prospective, single centre study, 177 consecutive patients with PAD undergoing PTA were enrolled, and treated with dual antiplatelet therapy with aspirin and a P2Y12 inhibitor. Platelet function was assessed on blood samples obtained within 24 h from PTA by light transmission aggregometry (LTA) using arachidonic acid (AA) and adenosine diphosphate (ADP) as agonists of platelet aggregation. High on-treatment platelet reactivity (HPR) was defined by LTA ≥ 20% if induced by AA, and LTA ≥ 70% if induced by ADP. Follow up was performed to record outcomes (death, major amputation, target vessel re-intervention, acute myocardial infarction and/or myocardial revascularisation, stroke/TIA, and bleeding).

RESULTS

HPR by AA and HPR by ADP were found in 45% and 32% of patients, respectively. During follow up (median duration 23 months) 23 deaths (13%) were recorded; 27 patients (17.5%) underwent target limb revascularisation (TLR), two (1.3%) amputation, and six (3.9%) myocardial revascularisation. Twenty-four patients (15.6%) experienced minor bleeding. On multivariable analysis, HPR by AA and HPR by ADP were independent predictors of death [HR 3.8 (1.2-11.7), p = .023 and HR 4.8 (1.6-14.5), p = .006, respectively]. The median value of LTA by ADP was significantly lower in patients with bleeding complications than in those without [26.5% (22-39.2) vs. 62% (44.5-74), p < .001). LTA by ADP ≤ 41% was independently associated with bleeding HR 14.6 (2.6-24.0), p = .001] on multivariable analysis.

CONCLUSIONS

In this study a high prevalence of on-clopidogrel and aspirin high platelet reactivity was found, which was significantly associated with the risk of death. Conversely, a low on-clopidogrel platelet reactivity was associated with a higher risk of bleeding. These results document that the entity of platelet inhibition is associated with both thrombotic and bleeding complications in PAD patients.

Antiplatelet and anticoagulant for prevention of reocclusion in patients with atrial fibrillation undergoing endovascular treatment for low extremity ischemia

Background

The purpose of this study is to report the efficacy of the mono antiplatelet plus anticoagulation therapy for prevention of reocclusion in patients with atrial fibrillation (AF) undergoing endovascular treatment for lower extremity ischemia.

Methods

From March 2014 to July 2016, 32 (21 males; range, 68-84 years) patients were submitted to endovascular therapy for low extremity ischemia with AF and all were treated with endovascular treatments to correct underlying lesions. Then 20 patients receive aspirin plus rivaroxaban post-operation and 12 patients receive aspirin plus warfarin to prevent reocclusion.

Results

Complete reconstruction of occluded femopopliteal arteries with unimpeded blood flow to legs were successfully obtained in all 32 patients; 12 (37.5%) patients had acute ischemia, 17 (53.1%) patients had chronic ischemia, 3 (9.4%) patients had acute on chronic ischemia. Endovascular treatments including percutaneous transluminal angioplasty (PTA) and stenting were performed to correct residual lesions after the thrombolytic/thrombectomy procedure or to correct native lesions for chronic patients. All 32 patients showed significant improvements in symptoms and 4 patients improved completely. The mean ankle-brachial index (ABI) had risen from 0.43±0.21 preoperatively to 0.81±0.16 postoperatively (P<0.01), and the primary patency rates were 88.9% at 12 months, and 81.5% at 24 months. No episodes of major bleeding and only one patient showed positive fecal occult blood tests during the follow-up.

Conclusions

The mono antiplatelet plus anticoagulation therapy offers a safe and effective alternative for prevention of reocclusion in patients with AF undergoing endovascular treatment for lower extremity ischemic.

Critical evaluation on proper antithrombotic treatment in different groups of patients undergoing vascular surgery

Antithrombotic treatment including anticoagulants and antiplatelets has evolved during the last decades, and several recommendations have been included in the latest guidelines regarding the proper management of patients undergoing vascular surgery. However, there are significant differences compared to older recommendations, and indications vary among patients with peripheral artery disease, carotid disease, and abdominal aortic aneurysm. In this mini review, we critically evaluate all these data to produce useful conclusions for everyday clinical practice.

Increased plasma olfactomedin 2 after interventional therapy is a predictor for restenosis in lower extremity arteriosclerosis obliterans patients

Animal studies have indicated that olfactomedin 2 (OLFM2) is involved in the process of vascular remolding. The aim of the present study was to investigate circulating OLFM2 levels in lower extremity arteriosclerosis obliterans (LEASO) patients and the association of OLFM2 with postoperative restenosis in patients. A total of 203 LEASO patients were enrolled in the present study. Plasma OLFM2 was measured before and 6 h after interventional therapy. After 6 months, patients were divided into a restenosis group and a non-restenosis group. Inter-group and intra-group differences in plasma OLFM2 were compared. The correlation between plasma OLFM2 and the severity of restenosis was analyzed by Spearman's correlation analysis. An receiver operating characteristic (ROC) curve was used to evaluate the predictive efficacy of plasma OLFM2 on restenosis. Logistic regression was used to determine the risk factors for restenosis. Postoperative OLFM2 in the restenosis group was significantly higher compared with the non-restenosis group (34.07 ± 5.76 ng/mL vs. 19.53 ± 2.99 ng/mL). No significant difference in preoperative plasma OLFM2 levels was identified between the two groups (10.92 ± 2.49 ng/mL vs. 11.54 ± 3.18 ng/mL). Postoperative OLFM2 levels were positively correlated with the severity of restenosis (r = 0.728, p < .001). The area under the ROC curve was 0.902 (95% confidence interval (CI): 0.874-0.965), with a cutoff value of 26.91 ng/mL (95% CI: 26.16-28.32). Plasma OLFM2 was an independent risk factor for restenosis. Our results suggest that plasma OLFM2 is a potential biomarker for restenosis and may be a novel target for the treatment of restenosis.

Current Status of Arterial Revascularization for the Treatment of Critical Limb Ischemia in Infrainguinal Atherosclerotic Disease

Critical limb ischemia (CLI) is the most severe form of peripheral arterial disease (PAD) that may result in limb loss and even death; thus, the fast and proper treatment should be employed as earlier as possible to prevent these catastrophic consequences. Arterial revascularization is almost always an indispensable treatment option for CLI. Although both endovascular and surgical revascularization procedures have an important role, nowadays, the hybrid revascularization as a combination of these revascularization procedures has also gained increasing popularity in the treatment of patients with CLI. This review provides an update on the arterial revascularization strategies for the treatment of CLI.

Review of aspirin and clopidogrel resistance in peripheral arterial disease

OBJECTIVE

Aspirin resistance (AR) and clopidogrel resistance (CR) are terms used to describe a reduction in the medication's efficacy in inhibiting platelet aggregation despite regular dosing. This review gives context to the clinical role and implications of antiplatelet resistance in peripheral arterial disease (PAD).

METHODS

A review of English-language literature on AR and CR in PAD involving human subjects using PubMed and MEDLINE databases was performed in April 2017. A total of 2075 patients in 22 relevant studies were identified. To give this issue context, a review of the larger, more established literature on antiplatelet resistance in coronary disease was undertaken, identifying significant research associating resistance to major adverse cardiovascular events (MACEs).

RESULTS

Studies in the coronary arterial disease literature have strongly associated antiplatelet resistance with increased MACE. Prevalence of AR or CR in coronary disease appears to be >55% for each in some studies. Meta-analyses of >50 studies revealed that AR and CR are significantly associated with MACE (relative risk of 2.09 and 2.8, respectively). This adds further weight to the literature reporting antiplatelet resistance as an independent predictor of and a threefold risk factor for major adverse cardiovascular events. The prevalence of resistance in PAD in this review was comparable to that in the coronary disease literature, with AR and CR prevalence up to 60% and 65%, respectively. There is evidence that the adverse effects of antiplatelet resistance are significant in PAD. In fact, research directly studying stent thrombosis populations with either coronary arterial disease or PAD revealed more significantly impaired platelet responsiveness to clopidogrel and aspirin in PAD compared with similar individuals with coronary disease. AR in PAD was found in studies to be a significant risk factor for iliofemoral stent reocclusion (P = .0093) and stroke in patients with symptomatic carotid disease (P = .018). CR was found to be a significant, independent risk factor in predicting ischemic outcomes in several recent PAD studies (P < .0001). Loss-of-function carriers of enzyme CYP2C19, important in clopidogrel metabolism, have a 30% greater risk of ischemic events (P < .001). Importantly, less antiplatelet drug resistance may be encountered with newer antiplatelet agents, including ticagrelor and prasugrel, because of reduced enzymatic polymorphisms.

CONCLUSIONS

The limited research addressing AR and CR in PAD suggests that further research is required to clarify the role of platelet assays and potential for individualized antiplatelet therapy.

Peripheral interventions and antiplatelet therapy: Role in current practice

Peripheral arterial disease (PAD) is a common disorder associated with a high risk of cardiovascular mortality and continues to be under-recognized. The major risk factors for PAD are similar to those for coronary and cerebrovascular disease. Management includes exercise program, pharmacologic therapy and revascularization including endovascular and surgical approach. The optimal revascularization strategy, endovascular or surgical intervention, is often debated due to the paucity of head to head randomized controlled studies. Despite significant advances in endovascular interventions resulting in increased utilization over surgical bypass, significant challenges still remain. Platelet activation and aggregation after percutaneous transluminal angioplasty of atherosclerotic arteries are important risk factors for re-occlusion/restenosis and life-threatening thrombosis following endovascular procedures. Antiplatelet agents are commonly prescribed to reduce the risk of myocardial infarction, stroke and death from cardiovascular causes in patients with PAD. Despite an abundance of data demonstrating efficacy of antiplatelet therapy in coronary artery disease and cerebrovascular disease, there is a paucity of clinical information, clinical guidelines and randomized controlled studies in the PAD population. Hence, data on antiplatelet therapy in coronary interventions is frequently extrapolated to peripheral interventions. The aim of this review article is to elucidate the current data on revascularization and the role and duration of antiplatelet and anticoagulant therapy in re-vascularized lower limb PAD patients.

Future research directions to improve fistula maturation and reduce access failure

With the increasing prevalence of end-stage renal disease, there is a growing need for hemodialysis. Arteriovenous fistulae (AVF) are the preferred type of vascular access for hemodialysis, but maturation and failure continue to present significant barriers to successful fistula use. AVF maturation integrates outward remodeling with vessel wall thickening in response to drastic hemodynamic changes in the setting of uremia, systemic inflammation, oxidative stress, and pre-existent vascular pathology. AVF can fail due to both failure to mature adequately to support hemodialysis and development of neointimal hyperplasia that narrows the AVF lumen, typically near the fistula anastomosis. Failure due to neointimal hyperplasia involves vascular cell activation and migration and extracellular matrix remodeling with complex interactions of growth factors, adhesion molecules, inflammatory mediators, and chemokines, all of which result in maladaptive remodeling. Different strategies have been proposed to prevent and treat AVF failure based on current understanding of the modes and pathology of access failure; these approaches range from appropriate patient selection and use of alternative surgical strategies for fistula creation, to the use of novel interventional techniques or drugs to treat failing fistulae. Effective treatments to prevent or treat AVF failure require a multidisciplinary approach involving nephrologists, vascular surgeons, and interventional radiologists, careful patient selection, and the use of tailored systemic or localized interventions to improve patient-specific outcomes. This review provides contemporary information on the underlying mechanisms of AVF maturation and failure and discusses the broad spectrum of options that can be tailored for specific therapy.