Anti-Thrombotic Therapy in peripheral arterial disease

Question 1

Management of antiplatelet in carotid artery stenosis

Answer 1

Asymptomatic
-SAPT e.g. clopidogrel 75mg OD or aspirin 75mg OD

Post carotid artery stenting

• DAPT for 1 month: aspirin 75mg OD AND clopidogrel 75mg OD
• Then SAPT e.g. clopidogrel 75mg OD or aspirin 75mg OD

Carotid endarterectomy
-SAPT e.g. clopidogrel 75mg OD or aspirin 75mg OD

Question 2

Management of antiplatelet in LEAD

Answer 2

Asymptomatic
-No antiplatelet required

Symptomatic
-SAPT e.g. clopidogrel 75mg OD or aspirin 75mg OD

Revascularisation percutaneous e.g. angioplasty

• DAPT for 1 month: aspirin 75mg OD AND clopidogrel 75mg OD
• SAPT thereafter likely clopidogrel 75mg OD
• UNLESS: recent MI in past year, may need to continue DAPT for longer

Revascularisation bypass

• SAPT likely clopidogrel 75mg
• Can consider using warfarin (INR ~ 2)

Question 3

Carotid artery stenosis antiplatelet summary

Answer 3

In patients with symptomatic carotid stenosis, long-term SAPT is recommended IA

DAPT with aspirin and clopidogrel is recommended for at least 1 month after CAS IB

In patients with asymptomatic >50% carotid artery stenosis, long-term antiplatelet therapy (commonly low dose aspirin) should be considered when the bleeding risk is low IIaC

Question 4

LEAD antiplatelet summary

Answer 4

Long-term SAPT is recommended in symptomatic patients. IA

Long-term SAPT is recommended in all patients who have undergone revascularization. IC

SAPT is recommended after infra-inguinal bypass surgery. IA

In patients requiring antiplatelet therapy, clopidogrel may be preferred over aspirin. IIbB

Vitamin K antagonists may be considered after autologous vein infra-inguinal bypass. IIbB

DAPT with aspirin and clopidogrel for at least 1 month should be considered after infra-inguinal stent implantation. IIaC

DAPT with aspirin and clopidogrel may be considered in below-the-knee bypass with a prosthetic graft. IIbB Because of a lack of proven benefit, antiplatelet therapy is not routinely indicated in patients with isolated asymptomatic LEAD. IIIA

Question 5

Management of antiplatelet in LEAD in those requiring anti-coagulation e.g. AF

Answer 5

Patients who are asymptomatic with LEAD OR have undergone bypass surgery
-use oral anti-coagulation alone e.g. warfarin INR 1.5 - 2.5

Patients with LEAD that have undergone a endovascular intervention
LOW-BLEEDING RISK: use DAPT for 1 month e.g. Warfarin AND clopidogrel 75mg OD, DAPT may be continued for 1 year in high-risk ACS patients e.g. had a stent
HIGH-BLEEDING RISK: SAPT with warfarin

Risk of bleeding must be weighed against risk of CTLI and graft occlusion

Question 6

Summary management of antiplatelet in LEAD in those requiring anti-coagulation e.g. AF

Answer 6

In patients with PADs and AF, DOAC/warfarin is recommended

• is recommended when the CHA2DS2-VASc score is more or equal to 2 IA
• should be considered in all other patients. IIaB

In patients with PADs who have an indication for OAC (e.g. AF or mechanical prosthetic valve), oral anticoagulants alone should be considered. IIaB

After endovascular revascularization, aspirin or clopidogrel should be considered in addition to OAC for at least 1 month if the bleeding risk is low compared with the risk of stent/graft occlusion. IIaC

After endovascular revascularization,OAC alone should be considered if the bleeding risk is high compared with the risk of stent/graft occlusion. IIaC

OAC and SAPT may be considered beyond 1 month in high ischaemic risk patients or when there is another firm indication for long-term SAPT. IIbC

Question 7

Post carotid artery stenting

Answer 7

• DAPT for 1 month: aspirin 75mg OD AND clopidogrel 75mg OD

- Then SAPT e.g. clopidogrel 75mg OD or aspirin 75mg OD

Question 8

Management of antiplatelet in LEAD in those requiring anti-coagulation e.g. AF

Answer 8

LOW-BLEEDING RISK: use DAPT for 1 month e.g. Warfarin/DOAC AND clopidogrel 75mg OD, DAPT may be continued for 1 year in high-risk ACS patients e.g. had a stent

HIGH-BLEEDING RISK: SAPT with warfarin/DOAC

Question 9

Asymptomatic LEAD

Answer 9

No antiplatelet

Question 10

Symptomatic LEAD

Answer 10

Clopidogrel 75mg OD

Question 11

Revascularisation percutaneous e.g. angioplasty in LEAD

Answer 11

• DAPT for 1 month: aspirin 75mg OD AND clopidogrel 75mg OD
• SAPT thereafter likely clopidogrel 75mg OD
• UNLESS: recent MI in past year, may need to continue DAPT for longer