Antithrombotic Therapy in Peripheral Arterial Occlusive Disease

Abstract

Atherosclerosisis the cause of the vast majority of cases of chronic peripheralarterial occlusive disease. The arteries most frequently involved, inorder of occurrence, are the femoropopliteal-tibial, aortoiliac, carotid and vertebral, splanchnic and renal, and brachiocephalic.Fibromuscular dysplasia, inflammatory arteritides, and congenitalarterial malformations are much rarer causes of arterial insufficiency.The causes of acute arterial occlusion are embolism, thrombosis, andtrauma. The goals of therapy in chronic arterial occlusive disease areto relieve ischemic symptoms (intermittent claudication and rest pain), to alleviate disability, and to prevent progression that might lead togangrene and limb loss. The objectives of therapy in acute arterialocclusion are to restore blood flow and to preserve life and limb.Antithrombotic therapy is a rational consideration in patients withperipheral arterial occlusive disease. In chronic disease, antithrombotic therapy is designed to prevent progression andthrombotic occlusion or to prevent thrombotic complications aftervascular reconstructions and other interventions. In acute arterialocclusion from embolism or thrombosis, effective anticoagulant therapywill prevent propagation of thrombi into proximal and distal arterialbranches with attendant compromise of collateral flow; may preventreocclusion after surgical or interventional procedures to reestablishflow; or, in the case of embolism, may prevent recurrence. Theantithrombotic agents available are anticoagulants, antiplateletagents, thrombolytic drugs, and dextran (Table 1). Table 1Summary of Antithrombotic Therapy in Peripheral Vascular Disease Clinical Problem Antithrombotic Therapy Grade of Recommendation Chronic lower extremity ischemia Aspirin (to reduce risk of stroke and MI) 1C Clopidogrel 2A Claudication Aspirin (to reduce risk of stroke and MI) 1C Cilostazol (in addition to aspirin) 2A Acute arterial occlusion and ischemia Heparin 1C Intra-arterial thrombolytic therapy (tPA) 2B Intraoperative anticoagulation during vascular surgery Heparin 1A Infrainguinal vein bypass Aspirin (to reduce risk of stroke and MI) 1C Clopidogrel (unable to take aspirin) 1C Infrainguinal prosthetic bypass Aspirin (with or without dipyridamole) 1A Infrainguinal bypass at high thrombotic risk Aspirin and warfarin 1B Carotid endarterectomy Aspirin 1A Open table in a new tab