Antithrombotic Treatment in Lower Extremity Peripheral Arterial Disease

Paclitaxel-coated balloon versus paclitaxel-eluting stent for femoropopliteal arterial disease: A meta-analysis

BACKGROUND

Paclitaxel-coated balloon (PCB) and paclitaxel-eluting stent (PES) are widely used in femoropopliteal arterial disease (FPAD), while the comparison of their clinical benefit is inconclusive. This meta-analysis aimed to compare the efficacy between PCB and PES for FPAD.

METHODS

Three internet databases were searched for eligible randomized controlled trials (RCTs). Random-effects model was used for pooled clinical outcomes grouped by PCB or PES, following with an indirect comparison. Subgroup analysis was planned according to age, gender, history of smoking, hypertension, and diabetes.

RESULTS

Twenty-five RCTs encompassing 2806 patients were included. There were no significant differences between PCB and PES concerning the incidence of primary patency rate (risk of restenosis [RR]: 0.925; 95% CI: 0.815-1.049; P = .222), target lesion revascularization (TLR) (RR: 1.248; 95% CI: 0.798-1.952; P = .332), death (RR: 1.130; 95% CI: 0.436-2.930; P = .801), restenosis (RR: 1.012; 95% CI: 0.647-1.581; P = .959), amputation (RR: 1.000; 95% CI: 0.314-3.181; P = 1.000), and thrombosis (RR: 0.240; 95% CI: 0.049-1.180; P = .079). Subgroup analysis showed a lower primary patency rate in patients ≥ 70-year-old (RR: 0.703; 95% CI: 0.510-0.968; P = .031) and an increased risk of TLR when diabetes proportion was ≥ 40.0% (RR: 1.755; 95% CI: 1.013-3.042; P = .045) with PCB. Moreover, PCB might increase mortality in smokers (RR: 1.957; 95% CI: 1.000-3.828; P = .050).

CONCLUSIONS

Regarding safety, no significant differences was found between PCB and PES. Further large-scale RCTs should be conducted based on the direct comparison results.

Focus on the Prevention of Acute Limb Ischemia: Centrality of the General Practitioner from the Point of View of the Internist

The thrombotic mechanism, being common to peripheral arterial disease (PAD), acute myocardial infarction (AMI), and stroke, is responsible for the highest number of deaths in the western world. However, while much has been done for the prevention, early diagnosis, therapy of AMI and stroke, the same cannot be said for PAD, which is a negative prognostic indicator for cardiovascular death. Acute limb ischemia (ALI) and chronic limb ischemia (CLI) are the most severe manifestations of PAD. They both are defined by the presence of PAD, rest pain, gangrene, or ulceration and we consider ALI if symptoms last less than 2 weeks and CLI if they last more than 2 weeks. The most frequent causes are certainly atherosclerotic and embolic mechanisms and, to a lesser extent, traumatic or surgical mechanisms. From a pathophysiological point of view, atherosclerotic, thromboembolic, inflammatory mechanisms are implicated. ALI is a medical emergency that puts both limb and the patient's life at risk. In patients over age 80 undergoing surgery, mortality remains high reaching approximately 40% as well as amputation approximately 11%. The purpose of this paper is to summarize the scientific evidence on the possibilities of primary and secondary prevention of ALI and to raise awareness among doctors involved in the management of ALI, in particular by describing the central role of the general practitioner.

Efficacy and safety evaluation of rivaroxaban vs. warfarin among non-valvular atrial fibrillation patients undergoing lower extremity revascularization

Introduction

The efficacy and safety of antithrombotic strategies remain uncertain in patients with atrial fibrillation undergoing lower-extremity revascularisation.

Materials and methods

Between January 2011 and November 2021, 319 patients with atrial fibrillation after lower-extremity revascularisation received rivaroxaban or warfarin treatment as anticoagulation regimens with different antiplatelet therapy strategies. The primary efficacy outcome was the composite of acute limb ischaemia, major amputation for vascular causes, myocardial infarction, ischaemic stroke, clinically driven target lesion revascularisation, and death from vascular causes. The safety outcomes were major bleeding events according to the International Society on Thrombosis and Haemostasis classification criteria.

Results

A total of 178 and 141 patients received rivaroxaban and warfarin treatments, respectively, after revascularisation with or without antiplatelet regimens. The incidence of the primary efficacy outcome at 36 months in the rivaroxaban group (44 patients, 24.7%) tended to be lower than that in the warfarin group (43 patients, 30.5%) (hazard ratio, 0.870; 95% confidence interval, 0.565–1.339; P = 0.527). The incidence of the secondary efficacy outcomes decreased in the rivaroxaban group (56 patients, 31.6%) compared with that in the warfarin group (61 patients, 43.2%). Major bleeding events occurred in three patients (1.7%) in the rivaroxaban group and five patients (3.5%) in the warfarin group; no significant difference in fatal or intracranial bleeding was observed between the groups.

Conclusion

This study describes practical experience regarding the use of rivaroxaban and warfarin in patients with peripheral arterial disease complicated by non-valvular atrial fibrillation following endovascular intervention. The efficacy and safety outcomes do not differ significantly between rivaroxaban and warfarin.

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.