The Role for Combined Antithrombotic Therapy With Platelet and Coagulation Inhibition After Lower Extremity Revascularization

2021 ◽  
Vol 14 (7) ◽  
pp. 796-802
Author(s):  
E. Hope Weissler ◽  
Victor Aboyans ◽  
Rupert Bauersachs ◽  
Marianne Brodmann ◽  
Sigrid Nikol ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Antithrombotic Therapy ◽  
Lower Extremity Revascularization ◽  
Coagulation Inhibition

Antithrombotic Therapy in Lower Extremity Artery Disease

2020 ◽  
Vol 18 (3) ◽  
pp. 215-222 ◽  
Author(s):  
Mislav Vrsalovic ◽  
Victor Aboyans
Keyword(s):  
Lower Extremity ◽  
Antiplatelet Therapy ◽  
Antithrombotic Therapy ◽  
Cardiovascular Events ◽  
Cardiovascular Outcomes ◽  
Lower Limbs ◽  
Stent Type ◽  
Increased Risk ◽  
Artery Disease ◽  
Lower Extremity Artery Disease

Lower extremity artery disease (LEAD) is a marker of a more advanced atherosclerotic process often affecting multiple vascular beds beyond the lower limbs, with a consequent increased risk for all-cause and cardiovascular mortality. Antithrombotic therapy is the cornerstone of management of these patients to prevent ischaemic cardiovascular and limb events and death. In patients with symptomatic LEAD, the efficacy of aspirin has been established long ago for the prevention of cardiovascular events. In the current guidelines, clopidogrel may be preferred over aspirin following its incremental ability to prevent cardiovascular events, while ticagrelor is not superior to clopidogrel in reducing cardiovascular outcomes. Dual antiplatelet therapy (DAPT, aspirin with clopidogrel) is currently recommended for at least 1 month after endovascular interventions irrespective of the stent type. Antiplatelet monotherapy is recommended after infra-inguinal bypass surgery, and DAPT may be considered in below-the-knee bypass with a prosthetic graft. In symptomatic LEAD, the addition of anticoagulant (vitamin K antagonists) to antiplatelet therapy increased the risk of major and life-threatening bleeding without benefit regarding cardiovascular outcomes. In a recent trial, low dose of direct oral anticoagulant rivaroxaban plus aspirin showed promising results, not only to reduce death and major cardiovascular events, but also major limb events including amputation. Yet, this option should be considered especially in very high risk patients, after considering also the bleeding risk. Despite all the evidence accumulated since >40 years, many patients with LEAD remain undertreated and deserve close attention and implementation of guidelines advocating the use of antithrombotic therapies, tailored according to their level of risk.

Applicability of the VOYAGER trial criteria: a cohort study on patients in the nationwide Danish Vascular Registry

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
M Soegaard ◽  
P.B Nielsen ◽  
F Skjoeth ◽  
T.B Larsen ◽  
N Eldrup
Keyword(s):  
Myocardial Infarction ◽  
Lower Extremity ◽  
Major Adverse Cardiovascular Events ◽  
Funding Source ◽  
Inclusion Criteria ◽  
Private Company ◽  
Exclusion Criteria ◽  
Dual Pathway ◽  
Event Rates ◽  
Lower Extremity Revascularization

Abstract Introduction Peripheral artery disease (PAD) carries a high risk of debilitating stroke, myocardial infarction, and death. The VOYAGER PAD trial investigates whether rivaroxaban 2.5 mg plus aspirin vs aspirin alone leads to a reduction in major adverse cardiovascular events (MACE) in patients with symptomatic PAD undergoing revascularization. However, it is unclear whether patients enrolled in VOYAGER PAD reflect those undergoing lower extremity revascularization in daily clinical practice. Purpose To describe the proportion of patients eligible for the VOYAGER PAD trial within the nationwide Danish Vascular Registry (DVR), the reasons for ineligibility, and rates of cardiovascular outcomes in VOYAGER-eligible and VOYAGER-ineligible patients. Methods We identified and characterized all patients from 2000–2016 undergoing open surgical or endovascular revascularization for symptomatic PAD in the DVR and applied the VOYAGER inclusion and exclusion criteria. We computed one-year rates per 100 person-years of VOYAGER PAD trial endpoints of MACE, myocardial infarction, ischemic stroke, major amputation, major bleeding, cardiovascular (CV) death, and all cause death. Results In the DVR, 32,911 patients underwent lower extremity revascularization for symptomatic PAD and were evaluated for eligibility. Among these, 32.2% had at least one exclusion criteria and an additional 40.6% without exclusion criteria did not fulfil inclusion criteria. The “VOYAGER-eligible” population therefore comprised 27.2% of the identified patients (Figure 1A). Main reasons for exclusion were atrial fibrillation (30.7%), poorly regulated hypertension (19.6%), PCI or ACS within 12 months before (16.0%), treatment with strong inhibitors or inducers of cytochrome P450 (9.2%), active cancer (8.8%), and severe renal failure (8.3%). Main reasons for non-inclusion were aorto-iliac procedures (79.0%), non-successful revascularization (13.1%), and age<50 years (7.1%). Compared with “VOYAGER-eligible” patients, event rates were slightly lower among patients in the DVR not fulfilling inclusion criteria and markedly higher for “VOYAGER excluded” patients (Figure 1B). Conclusion In this nationwide cohort of symptomatic PAD patients undergoing lower extremity revascularization, 27.2% full filled the inclusion and exclusion criteria for dual pathway therapy in the VOYAGER PAD trial. Non-inclusion predominantly related to aorto-iliac procedures and were associated with lower event rates. Future studies are needed to clarify if these patients could also benefit from dual pathway therapy. Figure 1 Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Bayer AG, Berlin, Germany

scholarly journals IP189. Lower Extremity Revascularization in Diabetic and Nondiabetic Patients

2016 ◽  
Vol 63 (6) ◽  
pp. 114S-115S
Author(s):  
Jeremy D. Darling ◽  
Peter A. Soden ◽  
Sara L. Zettervall ◽  
Raul J. Guzman ◽  
Mark C. Wyers ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Lower Extremity Revascularization

scholarly journals Embolic Protection Devices Are Not Associated With Improved Outcomes of Atherectomy for Lower Extremity Revascularization

2021 ◽  
Vol 74 (3) ◽  
pp. e38-e39
Author(s):  
Arash Fereydooni ◽  
Halbert Bai ◽  
Donald Baril ◽  
Venita Chandra ◽  
Cassius I. Ochoa Chaar
Keyword(s):  
Lower Extremity ◽  
Embolic Protection ◽  
Improved Outcomes ◽  
Protection Devices ◽  
Lower Extremity Revascularization

scholarly journals Reintervention Index After Open and Endovascular Lower Extremity Revascularization in the Vascular Quality Initiative–Medicare Linked Datasets

2021 ◽  
Vol 74 (3) ◽  
pp. e312-e314
Author(s):  
Cassius I. Ochoa Chaar ◽  
Xinyan Zheng ◽  
Jialin Mao ◽  
Raul J. Guzman ◽  
Philip Goodney
Keyword(s):  
Lower Extremity ◽  
Lower Extremity Revascularization

Postoperative continuous catheter-infused local anesthetic reduces pain scores and narcotic use after lower extremity revascularization

Vascular ◽  
2017 ◽  
Vol 26 (3) ◽  
pp. 262-270 ◽  
Author(s):  
William Shutze ◽  
William P Shutze Jr ◽  
Purvi Prajapati ◽  
Gerald Ogola ◽  
Jordan Schauer ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Lower Extremity ◽  
Local Anesthetic ◽  
Wound Complications ◽  
X Rays ◽  
Readmission Rates ◽  
Pain Scores ◽  
Average Pain ◽  
Revascularization Procedures ◽  
Lower Extremity Revascularization

Objective Postoperative pain following lower extremity revascularization procedures is traditionally controlled with narcotic administration. However, this may not adequately control the pain and puts the patient at risk for complications from opiate use. Here we report an alternative strategy for pain management using a continuous catheter-infused local anesthetic into the operative limb. Design Retrospective case–control study. Methods Patients undergoing lower extremity revascularization procedures using continuous catheter-infused local anesthetic were compared to similar patients undergoing similar procedures during the same time period who did not receive continuous catheter-infused local anesthetic. Records were reviewed for pain scores, narcotics consumption, length of stay, need for postoperative chest X-ray, supplemental oxygen use, wound complications, and 30-day readmission. Results There were 153 patients (mean age 69.5 years) from September 2011 to December 2014 who underwent common femoral artery procedures, femoral-popliteal bypass, femoral-tibial bypass, popliteal aneurysm repair, popliteal to pedal bypass, popliteal artery thrombo-embolectomy, sapheno-popliteal venous bypass, or ilio-femoral bypass. There were no significant differences between the continuous catheter-infused local anesthetic ( n=57) and control ( n=96) groups regarding age, body mass index, cardiac history, diabetes, hypertension, and procedures performed. The continuous catheter-infused local anesthetic group showed better cumulative average pain scores, better high pain scores on postoperative days 1–3, and better average pain scores on postoperative days 2–3 ( P<0.03). The continuous catheter-infused local anesthetic group had lower median narcotics consumption on postoperative days 1–2 ( P=0.02). No differences were found in postoperative length of stay, urinary catheter use, number of postoperative chest X-rays, oxygen use, mobilization, or fever. Wound complications occurred in 8.8% of the continuous catheter-infused local anesthetic group and in 11.5% of controls (P=0.79). Readmission rates were 23% (continuous catheter-infused local anesthetic) and 21% (controls; P=0.84). Conclusion Postoperative continuous catheter-infused local anesthetic reduces pain scores and pain medication use compared to standard opiate therapy in these patients, without increasing wound complication or readmission rates. Continuous catheter-infused local anesthetic appeared to have no effect on the incidence of pulmonary complications, mobilization, or fever.

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