Prescribing patterns of antiplatelet agents are highly variable after lower extremity endovascular procedures

Abstract

Background: The use of antiplatelet and antithrombotic agents after peripheral vascular interventions is a common clinical practice despite a lack of clear convincing evidence or accepted practice guidelines. The goal of this study was to assess surgeons' prescribing practices after endovascular procedures for lower extremity arterial occlusive disease.

Methods: Attendees at a national vascular meeting were asked to complete a voluntary survey indicating their prescribing practices of antiplatelet/antithrombotic agents for the following procedures: iliac bare-metal stent, iliac covered stent, infrainguinal balloon angioplasty, infrainguinal bare-metal stent, infrainguinal covered stent, infrainguinal atherectomy, and lower extremity cryoplasty. The respondents were given choices of aspirin (ASA) alone, clopidogrel alone, ASA/clopidogrel combined, warfarin alone, or ASA/clopidogrel/warfarin combined. They were also asked to indicate their preferred length of treatment for each medication or combination of medications for each procedure: 1, 3, 6, or 12 months.

Results: There were 51 respondents (48 vascular surgeons and 3 vascular fellows) with an average of 11 ± 6.4 years of experience and practicing in a university hospital (48%), community hospital (44%), or combined university/Veterans A hospital (6%) setting. The majority of respondents (98%) prescribe an antiplatelet agent for patients with peripheral arterial disease using 81 mg of ASA preferentially. Most surgeons do not obtain genetic testing (i.e., cytochrome P450, polypeptide 19 [CYP2C19] polymorphism) for antiplatelet effectiveness. The most common antiplatelet/antithrombotic medication of choice after lower extremity endoluminal therapy was a combination of ASA/clopidogrel. However, the duration of medical treatment was variable, with a 1- to 3-month course being the most common. The use of the ASA/clopidogrel combination increased with further distal endovascular treatment and the placement of stents versus angioplasty. In the vast majority of ASA-only responses, ASA was administered for at least 12 months if not recommended for life. Although the majority of surgeons would recommend dual antiplatelet therapy (52-77%), there was no consensus regarding the duration of treatment.

Conclusions: The antiplatelet/antithrombotic prescribing practices of vascular surgeons after lower extremity endovascular procedures are highly variable. Multicenter randomized controlled trials are needed to define optimal treatment efficacy and define the much-needed practice guidelines.