A Review of Antithrombotic Treatment in Critical Limb Ischemia After Endovascular Intervention

Abstract

Endovascular intervention is often used to treat critical limb ischemia (CLI). Post-intervention treatment with antiplatelet and/or anticoagulant therapy has reduced morbidity and mortality due to cardiovascular complications. The purpose of this review is to shed light on the various pharmacologic treatment protocols for treating CLI following endovascular procedures. We reviewed the literature comparing outcomes after antithrombotic treatment for patients with CLI. We characterized antithrombotic therapies into three categories: (1) mono-antiplatelet therapy (MAPT) vs. dual antiplatelet therapy (DAPT), (2) MAPT vs. antiplatelet (AP) ? anticoagulant (AC) therapy, and (3) AC vs. AP ? AC therapy. Relevant results and statistics were extracted to determine differences in the rates of the following outcomes: (1) re-stenosis, (2) occlusion, (3) target limb revascularization (TLR), (4) major amputation, (5) major adverse cardiac events, (6) all-cause death, and (7) bleeding. Studies suggest that DAPT reduces post-surgical restenosis, TLR, and amputation for diabetic patients, without increasing major bleeding incidences, compared to MAPT. Also, AP ? AC therapy provides overall superior efficacy, with no difference in bleeding incidences, compared to antiplatelet alone. Additionally, the effects were significant for restenosis, limb salvage, survival rates, and cumulative rate of above ankle amputation or death. These results suggest that treatment with DAPT and AP ? AC might provide better outcomes than MAPT following the endovascular intervention for CLI, and that the ideal treatment may be related to the condition of the individual patient. However, the studies were few and heterogenous with small patient populations. Therefore, further large controlled studies are warranted to confirm these outcomes.

Use of Oral Anticoagulation and Diabetes Do Not Inhibit the Angiogenic Potential of Hypoxia Preconditioned Blood-Derived Secretomes

“…As previously mentioned, many patients requiring angiogenesis-promoting therapies for central/peripheral vasculopathy and chronic wounds, who would greatly benefit from new generation bioactive treatments such as hypoxia preconditioned blood-derived secretomes, routinely receive OA [ 27 , 40 , 41 ]. A better understanding of the effects that OA administration may have on the angiogenic potential of blood-derived secretomes is therefore a key prerequisite for advancing their clinical utility.…”

Continuous aspirin treatment improves cardiovascular events and all-cause mortality in hemodialysis patients with peripheral artery disease

“…However, post-procedure vessel wall damage, low shear stress, poor infrapopliteal outflow, and intimal hyperplasia are associated with conditions favorable for reocclusion and restenosis [ 19 , 20 ]. To prevent reocclusion and restenosis after PTA, researchers may consider dual antiplatelet therapy and antiplatelet plus anticoagulant therapy, which might provide improved outcomes in patients with critical limb ischemia [ 21 ]. Patients who receive PTA benefit from aspirin treatment in maintaining the patency of stenotic vessels after PTA and aspirin remains the mainstay antiplatelet agent in patients with PAD following revascularization interventions [ 22–24 ].…”

Principal predictors of major adverse limb events in diabetic peripheral artery disease: A narrative review

“…Symptomatic PAD patients who required LER often suffer from a higher MALE rate [ 36 ], but the use of a dual antiplatelet therapy (DAPT) for ≥6 months after the procedure seems to be a safe, correlated with a low bleeding rate, and effective intervention to reduce MALE incidence [ 183 ]. Evidences about anticoagulants in PAD encouraged new studies proving a safe combination with antiplatelet therapy and a superior efficacy in comparison with mono-antiplatelet therapy alone [ 184 ]. Anticoagulation protects from the incidence of ischemic events in PAD even in high risk patients with multiple comorbidities [ 185 ].…”