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Review
. 2021 Aug 9;118(31-32):528-535.
doi: 10.3238/arztebl.m2021.0157.

Antithrombotic Treatment for Peripheral Arterial Occlusive Disease

David Hardung  1 , Andrea Behne, Mehmet Boral, Carsten Giesche, Ralf Langhoff
Affiliations
Review

Antithrombotic Treatment for Peripheral Arterial Occlusive Disease

David Hardung et al. Dtsch Arztebl Int. .

Abstract

Background: Patients with peripheral arterial occlusive disease (PAOD) are at ele - vated risk for cardiovascular events and vascular events affecting the limbs. The goals of antithrombotic treatment are to keep vessels open after revascularization, to prevent cardiovascular events, and to lessen the frequency of peripheral ischemia and of amputation.

Methods: This review is based on pertinent publications retrieved by a selective literature search, with particular attention to meta-analyses, randomized controlled trials, and the German and European angiological guidelines.

Results: Diabetes mellitus and nicotine abuse are the main risk factors for lower limb PAOD. The evidence for the efficacy and safety of antithrombotic treatment in patients with PAOD is limited, in particular, after surgical or endovascular revascularization. Intensifying antithrombotic treatment with stronger antiplatelet therapy (APT), dual antiplatelet therapy (DAPT), or antiplatelet therapy combined with anticoagulation lowers the rate of peripheral revascularization (relative risk [RR] 0.89; 95% confidence interval [0.83; 0.94]), amputation (RR 0.63; [0.46; 0.86]), and stroke (RR 0.82; [0.70; 0.97]) but raises the risk of bleeding (RR 1.23; [1.04; 1.44]). Pre - dictors for peripheral vascular events include critical limb ischemia and having previously undergone a revascularization procedure or an amputation.

Conclusion: Antiplatelet therapy should only be intensified for a limited time, or if the risk of ischemia is high. Before and during intensified antiplatelet therapy, the risk of bleeding should be assessed and weighed against the risk of ischemia. No validated score is available to estimate the risk of hemorrhagic complications in patients with PAOD. New antithrombotic therapies should not be used indiscriminately, but should rather be reserved for selected groups of patients.

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Figures

Figure
Figure
Escalation/de-escalation of antiplatelet therapy APT, Antiplatelet therapy; DAPT, dual antithrombotic therapy; MACE, major adverse cardiovascular events; MALE, major adverse limb events; NOAC, non-vitamin-K-antagonist oral anticoagulant; OAC, oral anticoagulant; PAOD, peripheral arterial occlusive disease
See this image and copyright information in PMC

Comment in

  • Reasoning is too narrowly focused.
    Süss JD, Gawenda M. Süss JD, et al. Dtsch Arztebl Int. 2022 Mar 18;119(11):197. doi: 10.3238/arztebl.m2022.0046. Dtsch Arztebl Int. 2022. PMID: 35655348 Free PMC article. No abstract available.
  • Reasoning is to be welcomed.
    Egidi G. Egidi G. Dtsch Arztebl Int. 2022 Mar 18;119(11):197. doi: 10.3238/arztebl.m2022.0047. Dtsch Arztebl Int. 2022. PMID: 35655349 Free PMC article. No abstract available.
  • Patient registry available.
    Stausberg J, Hoffmann U, Malyar N. Stausberg J, et al. Dtsch Arztebl Int. 2022 Mar 18;119(11):198. doi: 10.3238/arztebl.m2022.0048. Dtsch Arztebl Int. 2022. PMID: 35655350 Free PMC article. No abstract available.
  • In reply.
    Hardung D. Hardung D. Dtsch Arztebl Int. 2022 Mar 18;119(11):198. doi: 10.3238/arztebl.m2022.0049. Dtsch Arztebl Int. 2022. PMID: 35655351 Free PMC article. No abstract available.

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