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DAPT after revascularization may prolong survival in patients with critical limb ischemia
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In patients with critical limb ischemia undergoing lower-extremity revascularization, dual antiplatelet therapy was linked with prolonged survival compared with aspirin monotherapy, but this benefit does not appear to extend to patients with claudication undergoing lower-extremity revascularization, researchers reported in the Journal of Vascular Surgery.
The retrospective analysis included prospective data from the Vascular Quality Initiative registry on 57,041 patients who underwent initial elective lower-extremity revascularization (bypass or endovascular) from 2003 to 2016. Patients identified for analysis were discharged on a regimen of aspirin monotherapy or aspirin plus a thienopyridine antiplatelet agent. The researchers calculated survival days from the date of the initial procedure until the time of death or end of follow-up (January 2016). The researchers also estimated models to predict the likelihood of being placed on DAPT and used inverse probability weighting to adjust for baseline differences in the likelihood of DAPT.
Overall, 15,985 patients underwent lower-extremity revascularization bypass (69% for critical limb ischemia [CLI]). Of those, 9,967 were discharged on aspirin monotherapy and 6,018 were discharged on DAPT, according to the findings. Among 41,056 patients who underwent endovascular lower-extremity revascularization (39% for CLI), 12,559 were discharged on aspirin monotherapy and 28,497 were discharged on DAPT.
The weighted Cox model determined the following HRs associated with DAPT, which were used to calculate survival rates for each intervention group: 0.91 for bypass-claudication (95% CI, 0.73-1.1); 0.86 for bypass-CLI (95% CI, 0.78-0.95; P = .003); 0.93 for endovascular-claudication (95% CI, 0.82-1.1); and 0.89 for endovascular-CLI (95% CI, 0.82-0.96). Both bypass and endovascular revascularization yielded HRs equating to a 1-year survival benefit (bypass, 93% vs. 92%; P = .001; endovascular, 93% vs. 92%; P = .005), and these benefits continued through 5 years (bypass, 80% vs. 78%; P = .004; endovascular, 76% vs. 73%; P = .002), according to the findings.
Bypass and endovascular revascularization conferred greater ongoing survival benefit for patients with CLI (bypass: 1 year, 88% vs. 87%; P = .01; bypass: 5 years, 70% vs. 66%; P = .04; endovascular: 1 year, 91% vs. 90%; P = .02; endovascular: 5 years, 71% vs. 67%; P = .01). The researchers found no discernible survival benefit in patients with claudication who underwent bypass or endovascular revascularization. Cox proportional hazards models for the entire sample revealed similar results: DAPT demonstrated a protective effect after both bypass and endovascular revascularization (HR = 0.81; 95% CI, 0.72-0.9 and HR = 0.89; 95% CI, 0.83-0.95, respectively).
In an analysis stratified by severity of peripheral artery disease, patients with CLI who were discharged on DAPT had improved survival (bypass: HR = 0.79; 95% CI, 0.7-0.9; endovascular: HR = 0.9; 95% CI, 0.82-0.98), but patients with claudication did not (bypass: HR = 1.12; 95% CI, 0.75-1.68; endovascular: HR = 0.89; 95% CI, 0.77-1.03).
“DAPT at time of discharge, compared with aspirin alone, is associated with increased survival after lower-extremity revascularization,” the researchers wrote. “This benefit was most evident in patients with CLI. Given these findings, there is a need to quantify the risk associated with DAPT, especially with regard to bleeding, so that clinicians can choose appropriate antiplatelet management for their patients.” – by Jennifer Byrne
Disclosure: The researchers report no relevant financial disclosures.
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