Antithrombotic therapy following reconstructive surgery for peripheral artery disease: A narrative review

Relevance. Reconstructive operations on limb arteries are one of the most important areas of vascular surgery (>30,000 interventions in Russia, 2024). Antithrombotic therapy is critically important for thrombosis prevention in early and late postoperative periods, yet unified clinical guidelines for its optimization considering surgery type, graft material, and comorbidities are lacking. Aim: to analyze contemporary data on the efficacy and safety of various antithrombotic therapy regimens following reconstructive operations on limb arteries. Materials and methods. Analysis of scientific literature data was performed. Results from 15 key studies (including 7 randomized controlled trials, 2 meta-analyses, 1 Cochrane review, large registries, and clinical guidelines) focusing on antithrombotic therapy after reconstructive limb artery operations were systematized. Analysis addressed efficacy/safety of different regimens (antiplatelets, anticoagulants, combination therapy) based on intervention type (open/endovascular), graft material (autologous vein / synthetic prosthesis), and reconstruction site. Results. Endovascular interventions: long-term single antiplatelet therapy should be prescribed post-endovascular intervention. Dual antiplatelet therapy is recommended only as a short course (1 month) and may be extended for high rethrombosis risk. Open surgery: dual antiplatelet therapy is justified after open vascular reconstructions with elevated thrombosis/occlusion risk. Aspirin combined with rivaroxaban (2.5 mg BID) reduces graft occlusion risk. Adding warfarin to prolonged therapy may offer benefits (especially for high graft thrombosis risk) but increases hemorrhagic complications. Conclusion. Antithrombotic therapy after reconstructive vascular surgery is individualized. It depends on: surgical approach (open/endovascular), vascular lesion topography, graft material (autologous vein / synthetic prosthesis), and comorbidities. Determining therapy intensity/duration requires balancing treatment benefits against hemorrhagic complication risks.

1. Qureshi M. I., et al. Antiplatelet and anticoagulant use in randomised trials of patients undergoing endovascular intervention for peripheral arterial disease: systematic review and narrative synthesis // European Journal of Vascular and Endovascular Surgery. – 2020. – Т. 60, № 1. – С. 77–87.

2. Wong K. H. F., et al. The CLEAR (Considering Leading Experts' Antithrombotic Regimes around peripheral angioplasty) survey: an international perspective on antiplatelet and anticoagulant practice for peripheral arterial endovascular intervention // CVIR endovascular. – 2019. – Т. 2, № 1. – С. 37.

3. Katsanos K., et al. Comparative efficacy and safety of different antiplatelet agents for prevention of major cardiovascular events and leg amputations in patients with peripheral arterial disease: a systematic review and network meta-analysis // PloS one. – 2015. – Т. 10, № 8. – С. e0135692.

4. Tepe G., et al. Management of peripheral arterial interventions with mono or dual antiplatelet therapy — the MIRROR study: a randomised and double-blinded clinical trial // European radiology. – 2012. – Т. 22, № 9. – С. 1998–2006.

5. Thott O., et al. Editor's Choice — Dual Antiplatelet Therapy Improves Outcome in Diabetic Patients Undergoing Endovascular Femoropopliteal Stenting for Critical Limb Ischaemia // European Journal of Vascular and Endovascular Surgery. – 2017. – Т. 53, № 3. – С. 403–410.

6. Desai K., Han B., Kuziez L., Yan Y., Zayed M. A. Literature review and meta-analysis of the efficacy of cilostazol on limb salvage rates after infrainguinal endovascular and open revascularization // J. Vasc. Surg. – 2021. – Т. 73, № 2. – С. 711–721.e3.

7. Bonaca M. P., et al. Rivaroxaban in peripheral artery disease after revascularization // New England Journal of Medicine. – 2020. – Т. 382, № 21. – С. 1994–2004.

8. Hiatt W. R., et al. Rivaroxaban and aspirin in peripheral artery disease lower extremity revascularization: impact of concomitant clopidogrel on efficacy and safety // Circulation. – 2020. – Т. 142, № 23. – С. 2219–2230.

9. Forster R. B., Lethaby A., Maxwell H., Acosta S., Prins M. H. Antiplatelet agents for preventing thrombosis after peripheral arterial bypass surgery // Cochrane Database of Systematic Reviews. – 2015. – № 2. – С. CD000535.

10. Belch J. J., et al. Results of the randomized, placebo-controlled clopidogrel and acetylsalicylic acid in bypass surgery for peripheral arterial disease (CASPAR) trial // Journal of Vascular Surgery. – 2010. – Т. 52, № 4. – С. 825–833, 833.e1–833.e2.

11. van Hattum E. S., et al. Bleeding increases the risk of ischemic events in patients with peripheral arterial disease // Circulation. – 2009. – Т. 120, № 16. – С. 1569–1576.

12. Johnson W. C., et al. Benefits, morbidity, and mortality associated with long-term administration of oral anticoagulant therapy to patients with peripheral arterial bypass procedures: a prospective randomized study // Journal of Vascular Surgery. – 2002. – Т. 35, № 3. – С. 413–421.

13. Monaco M., et al. Combination therapy with warfarin plus clopidogrel improves outcomes in femoropopliteal bypass surgery patients // Journal of Vascular Surgery. – 2012. – Т. 41, № 2. – С. 316–321.

14. Campbell W. B., Ridler B. M. F., Szymanska T. H. Two-year follow-up after acute thromboembolic limb ischaemia: the importance of anticoagulation // European Journal of Vascular and Endovascular Surgery. – 2000. – Т. 19, № 2. – С. 169–173.

15. Diener H. C., et al. Dabigatran for prevention of stroke after embolic stroke of undetermined source // New England Journal of Medicine. – 2019. – Т. 380, № 20. – С. 1906–1917.