Comparative Study Between Dual Antiplatelet Therapy and Continuous Heparin Infusion During the First 24 Hours After an Endovascular Procedure in Critical Limb Ischemia

Abstract

Introduction: Percutaneous transluminal angioplasty (PTA) is a well-established endovascular procedure for lower limb atherosclerosis, but dilated segments may occlude, even in the first postoperative hours, depending on the procedure itself or distal outflow. To prevent these events patients are treated with antithrombotic agents 1-5 or anticoagulated. The aim of our study was to compare dual antiplatelet treatment (DAPT) with aspirin and clopidogrel versus anticoagulation with continuous heparin infusion (CHI) in the first 24 postoperative hours in terms of patency, complications and reintervention rates at 30 days. Methods: Retrospective review experience of a prospectively maintained database of a single tertiary vascular center. 502 endovascular interventions were performed for lower limb ischemia between December 2013 and December 2018.Demographic, technical and follow-up data were recorded. Inclusion criteria were patients with critical limb ischemia (CLI) who has received endovascular treatment.Patients receiving DAPT were compared with those which received CHI in the first 24 postoperative hours. We analyzed local complications related to access such as bleeding, haematoma or pseudoaneurysm, any complication (local and general complications), occlusions, reinterventions, major amputations and primary patency at 30 days. Results: 341 procedures (68%) were performed to treat CLI. The mean age was 71,7 years (41-95 years)andthe majority were men (70,4%; 240). Diabetes was present in 82,7% (282) and chronic renal insufficiency in 42% (145). Treated segment was aortoiliac in 33 (9,7%), femoro-popliteal in 220 (64,5%) and distal vessels in 88 cases (25,8%). 283 received CHI until 2016, while 58 received DAPT after this year, following the recommended guidelines. Drug coated balloon was used in CHI group in 10 patients (3,5%) and 2 (3,4%) in DAPT (p 0.97).Stenting was used in 60 (21,1%) and 16 (27,6%) in CHI and DAPT groups respectively (p 0,28). We did not find any differences between groups regarding major bleeding (2,8% vs 0%; p 0,36) and iatrogenic pseudoaneurysm (4.2% vs 1,7%; p0,71). Any complication at 30-dayswas higher in CHI group (20,8% vs. 8,6%; p 0.03). Patency at 30 days were 92,2% in CHI vs. 94,8% in DAPT (p 0.248) whilst reintervention rate was 2,8% vs. 3,4% respectively(p 0.68).There was a trend in a higher amputation rate at 30-days, 7,4% vs 1,7%, CHI vs DSPT (p 0,08), and no differences in mortality rate, 3,5% in CHI and 1,7% in DAPT (p 0,41). Conclusion: CHI had more complications than DAPT in the first 24 hours post intervention, and a trend to higher amputation rate. There were no differences in primary patency rate, major bleedings nor pseudoaneurysms.