Antithrombotic Therapy in Patients with Peripheral Artery Disease: A Focused Review on Oral Anticoagulation

Abstract

Peripheral artery disease (PAD) is a major cause of morbidity and mortality but it is usually underdiagnosed and undertreated. Patients with PAD present dysregulated procoagulant, anticoagulant, and fibrinolytic pathways leading to arterial and venous thrombosis. The risk of several ischemic-related complications could be mitigated with appropriate antithrombotic therapy, which plays a central role in all types of PAD. For years, antiplatelets have been indicated in patients with symptomatic PAD or those who have undergone revascularization. Unfortunately, a non-negligible proportion of patients with PAD will suffer from adverse events during the follow-up, even despite proper medical therapies for the prevention of PAD complications. Thus, there is room for improving clinical outcomes in these patients. Given the implication of both, primary and secondary hemostasis in arterial thrombosis and the pathophysiology of PAD, the combination of antiplatelets and anticoagulants has emerged as a potential antithrombotic alternative to antiplatelets alone. In this narrative review article, we have highlighted the most recent evidence about antithrombotic therapy in PAD patients, with a special focus on oral anticoagulation. Certainly, COMPASS and VOYAGER PAD trials have shown promising results. Thus, rivaroxaban in combination with aspirin seem to reduce cardiovascular outcomes with a similar bleeding risk compared to aspirin alone. Nevertheless, results from real-world studies are needed to confirm these observations, and other trials will provide novel evidence about the safety and efficacy of emerging anticoagulant agents.

The association between ABO blood groups and TASC II classification in patients with peripheral artery disease

“…There is also an increasing trend in the use of anticoagulant agents in patients with peripheral vascular disease. 28 We also found in our study that as the severity of PAD increased, the number of patients using anticoagulants increased significantly. It would be more appropriate to conduct a large-scale study on this subject.…”

Biodegradable Electrospun Scaffolds as an Emerging Tool for Skin Wound Regeneration: A Comprehensive Review

“…Once the activated platelets connect with factors V, VIII, and IX, factor Xa is generated and added to the prothrombinase on the platelet’s surface, comprising of factors Xa and Va, which leads to a high level of thrombin and hastens the formation of the fibrin clot. The intrinsic and extrinsic pathways then come together, causing the production of fibrin subunits that link up, forming strands that bind the platelets and secure the plug in position [ 20 ]. The protein C/protein S/thrombomodulin (TM) system on endothelial cells is capable of deactivating factors Va and VIIIa, thus limiting clot formation to the damaged region.…”

The Role of the Coagulation System in Peripheral Arterial Disease: Interactions with the Arterial Wall and Its Vascular Microenvironment and Implications for Rational Therapies

“…Nowadays, antiplatelets represent the classical approach to limb-related and major cardiovascular events prevention in LEAD, and their use is currently recommended by the European Society of Cardiology (ESC) and the American Heart Association/American College of Cardiology (AHA/ACC) guidelines in: (i) patients with symptomatic Lower Extremity Artery Disease or who have undergone revascularization; (ii) all patients with carotid artery stenosis regardless of clinical symptoms and revascularization [ 172 , 173 , 174 ].…”