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

Evidence for antithrombotic treatment following lower extremity revascularization (LER) for peripheral artery disease (PAD) is limited, leading to weak and conflicting guideline recommendations and heterogeneous practice patterns. This variability in post-LER antithrombotic treatment raises quality-of-care issues that have long been under-studied. This Viewpoint reviews the most updated guidelines, currently-available evidence, and contemporary data about practice patterns and practitioner opinions in this area. Particular attention is paid to distinctions between antiplatelet therapy, anticoagulant therapy, and combination therapy in light of the recent VOYAGER-PAD (Vascular Outcomes Study of ASA [acetylsalicylic acid] Along with Rivaroxaban in Endovascular or Surgical Limb Revascularization for PAD) trial. The implications of VOYAGER-PAD pertaining to various subgroups of patients undergoing LER are explored. Overall, this Viewpoint argues for consideration of post-LER therapy targeted at both platelet function and the coagulation cascade, though further LER-specific analyses, including expected VOYAGER-PAD sub-analyses, are needed.

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Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

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Funding Support and Author Disclosures Dr. Weissler is supported by the National Heart, Lung, and Blood Institute (grant F32HL151181). Dr. Aboyans has received honoraria and is a speaker, an expert, or a member of steering committees from Amgen, Bayer, Novo Nordisk, Novartis, Bristol Myers Squibb/Pfizer, and Sanofi. Dr. Bauersachs has received speaker and consulting fees from Bayer, Bristol Myers Squibb, Daichii-Sankyo, and Pfizer. Dr. Brodmann has received consulting fees from Bayer Healthcare and Daiichi-Sankyo. Dr. Debus has received institutional grants from Bayer, Cook, and Terumo Aortic Advisory Boards. Dr. Patel has received research grants from AstraZeneca, Bayer, Janssen, the National Heart, Lung, and Blood Institute, and Medtronic; and is an advisory board member or a consultant for Bayer, Janssen, and AstraZeneca. Dr. Jones has received research grants from Boehringer Ingelheim and Medtronic; and is an advisory board member or a consultant for Bristol Myers Squibb, Bayer, and Janssen. Dr. Nikol has reported that she has no relationships relevant to the contents of this paper to disclose.