Symptomatic peripheral arterial disease: Aspirin simply is not enough.

We congratulate the efforts of Kindell et al1Kindell D.G. Marulanda K. Caruso D.M. Duchesneau E. Agala C. Farber M. et al.Incidence of venous thromboembolism in patients with peripheral arterial disease after endovascular intervention.J Vasc Surg Venous Lymphat Disord. 2023; 11: 61-69Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar to examine the incidence of venous thromboembolism (VTE) events among patients with peripheral arterial disease (PAD) undergoing endovascular intervention. Although VTE events after surgery have been extensively studied, and the association between atherosclerotic disease and spontaneous venous thrombosis has been established, a paucity of data is available on the occurrence of VTE after endovascular interventions.2Prandoni P. Bilora F. Marchiori A. Bernardi E. Petrobelli F. Lensing A.W.A. et al.An association between atherosclerosis and venous thrombosis.N Engl J Med. 2003; 348: 1435-1441Crossref PubMed Scopus (548) Google Scholar Using Medicare claims data, the authors were able to amass a database of >30,000 patients who had undergone percutaneous lower extremity endovascular intervention for infrainguinal PAD. The authors aimed to quantify the VTE rates, hypothesizing a lower rate for this cohort compared with their open revascularization counterparts. Particular interest was given to antiplatelet and anticoagulant usage within 365 days after the procedure. Their analysis identified an unforeseen high incidence of VTE of 5.6% at 90 days after endovascular intervention for PAD and striking gender disparities in prescription management. Patients with chronic limb-threatening ischemia have a high risk of cardiovascular and cerebrovascular morbidity and mortality, essentially described as “end-stage manifestation” of atherosclerotic disease. The importance of optimal medical therapy, including antithrombotic and antiplatelet agents, was included in the global vascular guidelines on the management of chronic limb-threatening ischemia.3Conte M.S. Bradbury A.W. Kolh P. White J.V. Dick F. Fitridge R. et al.Global vascular guidelines on the management of chronic limb-threatening ischemia.Eur J Vasc Endovasc Surg. 2019; 58: S1-S109.e33Abstract Full Text Full Text PDF PubMed Scopus (542) Google Scholar Additionally, several studies have supported the use of a combined antiplatelet and antithrombotic regimen in this patient population. The COMPASS (rivaroxaban for the prevention of major cardiovascular events in coronary or peripheral artery disease) trial has provided evidence for the use of rivaroxaban, in addition to aspirin, for reducing thrombotic outcomes in patients with chronic stable PAD.4Eikelboom J.W. Connolly S.J. Bosch J. Dagenais G.R. Hart R.G. Shestakovska O. et al.Rivaroxaban with or without aspirin in stable cardiovascular disease.N Engl J Med. 2017; 377: 1319-1330Crossref PubMed Scopus (1474) Google Scholar Furthermore, for patients with PAD who had undergone lower extremity revascularization, the VOYAGER PAD (efficacy and safety of rivaroxaban in reducing the risk of major thrombotic vascular events in subjects with symptomatic peripheral artery disease undergoing peripheral revascularization procedures of the lower extremities) trial found that rivaroxaban plus aspirin was associated with a significantly lower incidence of acute limb ischemia, major amputation for vascular causes, myocardial infarction, ischemic stroke, and death from cardiovascular causes compared with aspirin alone.5Bonaca M.P. Bauersachs R.M. Anand S.S. Debus S. Nehler M.R. Patel M.R. et al.Rivaroxaban in peripheral artery disease after revascularization.N Engl J Med. 2020; 382: 1994-2004Crossref PubMed Scopus (401) Google Scholar Despite this abundance of evidence, the authors identified that >50% of their studied patient population who had developed VTE had not been prescribed an anticoagulant or antiplatelet medication after intervention, highlighting a large opportunity to improve a significant healthcare gap in our PAD patient population. Another critical finding from their analysis was that women were less likely to be prescribed an anticoagulant after their procedure but were also more likely to develop VTE or deep vein thrombosis at all follow-up points (30, 90, and 365 days). Determining whether this is a cause-and-effect relationship will require further investigation; however, as they noted, female sex is an independent risk factor for the development of VTE, compounded by their PAD diagnosis and endovascular revascularization. This finding also emphasizes the danger of gender biases in healthcare. In further support, since 1984, the mortality rate of heart disease has been higher for women than for men. However, a study reported in the Journal of the American Heart Association found that when women had received the same interventions as men, their all-cause mortality was equivalent.6Alabas O.A. Gale C.P. Hall M. Rutherford M.J. Szummer K. Lawesson S.S. et al.Sex differences in treatments, relative survival, and excess mortality following acute myocardial infarction: national cohort study using the SWEDEHEART Registry.J Am Heart Assoc. 2017; 6: e007123Crossref PubMed Scopus (120) Google Scholar Future studies investigating the reasons behind these gender disparities in healthcare delivery could prove beneficial and help optimize strategies to improve outcomes. Incidence of venous thromboembolism in patients with peripheral arterial disease after endovascular interventionJournal of Vascular Surgery: Venous and Lymphatic DisordersVol. 11Issue 1PreviewVenous thromboembolism (VTE) is a well-known postoperative complication; however, the incidence of VTE after peripheral vascular intervention (PVI) has not been well described. Despite the minimally invasive nature of these procedures, the patients undergoing PVI have significant risk factors for the development of VTE. In the present study, our objective was to describe the short-term incidence of VTE after PVI, identify differences between sexes, and examine the periprocedural antiplatelet and anticoagulation regimens. Full-Text PDF