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Impact of dual antiplatelet therapy after lower extremity revascularization for chronic limb-threatening ischemia
Bala Ramanan1, Haekyung Jeon-Slaughter2, Xiaofei Chen3
1Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Tex.
Insights
Dual antiplatelet therapy (DAPT) improves survival and reduces amputation risk after lower extremity revascularization for chronic limb-threatening ischemia (CLTI). DAPT is recommended over mono antiplatelet therapy (MAPT) for better outcomes in CLTI patients.
Area of Science:
- Vascular Surgery
- Cardiology
- Clinical Outcomes Research
Background:
- Optimal antiplatelet strategy post-lower extremity revascularization for chronic limb-threatening ischemia (CLTI) remains undetermined.
- Current guidelines extrapolate data from coronary artery disease and stroke trials, necessitating CLTI-specific evidence.
- Understanding the impact of mono antiplatelet therapy (MAPT) versus dual antiplatelet therapy (DAPT) is crucial for patient management.
Purpose of the Study:
- To compare the effectiveness of MAPT versus DAPT in patients undergoing lower extremity revascularization for CLTI.
- To evaluate the impact of antiplatelet regimens on major amputation, survival, and reintervention rates.
- To provide evidence-based recommendations for antiplatelet therapy in this high-risk patient population.
Main Methods:
- Retrospective analysis of 50,890 patients in the Vascular Quality Initiative registry undergoing elective lower extremity revascularization for CLTI (2003-2018).
- Patients were stratified by discharge antiplatelet regimen: MAPT or DAPT.
- Outcomes included 30-day and 1-year major amputation, overall survival, amputation-free survival, target lesion reintervention, and thrombosis.
Main Results:
- DAPT was associated with improved 1-year amputation-free survival and overall survival compared to MAPT after both endovascular therapy (EVT) and open surgery (OS).
- MAPT was linked to a higher risk of 1-year major amputation after EVT but not OS.
- DAPT showed a reduced risk of target lesion reintervention after EVT, with no significant difference in thrombosis rates between MAPT and DAPT for either procedure.
Conclusions:
- Dual antiplatelet therapy (DAPT) at discharge positively impacts amputation-free and overall survival in CLTI patients undergoing EVT or OS.
- DAPT also reduces target lesion reintervention after EVT, suggesting improved long-term patency.
- While DAPT did not show a statistically significant impact on major amputation rates, its benefits on survival and reintervention warrant its consideration in CLTI management.
Objective:
The optimal antiplatelet regimen after lower extremity revascularization in patients with chronic limb-threatening ischemia (CLTI) is unknown because current recommendations are based on extrapolation of data from trials in coronary artery disease and stroke.
Methods:
We identified all patients undergoing an elective lower extremity revascularization for CLTI in the Vascular Quality Initiative registry discharged on a mono antiplatelet agent (MAPT) or dual antiplatelet therapy (DAPT).
Results:
From 2003 to 2018, 50,890 patients underwent revascularization procedures for CLTI, and were discharged on MAPT or DAPT. Of these, 33,781 patients underwent endovascular therapy (EVT), and 17,109 patients underwent open surgery (OS) procedures. The rate of major amputation at 30 days in the target limb in the EVT group was 0.3% and 0.4% in the OS group (P = .22). On Kaplan-Meier analyses, patients on MAPT at discharge had a higher risk of 1-year major amputation compared with DAPT after EVT but not after OS procedures. Patients on MAPT had lower overall survival and amputation-free survival at 30 days and 1 year compared with DAPT after both EVT and OS. At 1 year, the MAPT group was at higher risk for target lesion reintervention after EVT compared with the DAPT group (15.9% vs 13%; P = .0012). There was no significant difference in thrombosis at 1 year between the MAPT and DAPT groups either after EVT (3.9% vs 3.7%; P = .3048) or OS (3.1% vs 3.2%; P = .2893). On Cox regression analysis, DAPT was associated with improved survival but not major amputation after both EVT and OS.
Conclusions:
In patients with CLTI, DAPT at the time of discharge has a positive impact on amputation-free survival and overall survival after both EVT and OS as well as target lesion reintervention after EVT. DAPT was not associated with a positive impact on major amputation after either EVT or OS.
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