P2Y12 Inhibitor Monotherapy Is Superior to Aspirin Monotherapy in Chronic Limb-Threatening Ischemia Postendovascular Intervention

Abstract

Antiplatelet monotherapy is recommended in patients with peripheral arterial disease to reduce adverse limb and cardiovascular events. While there is some evidence of improved outcomes with P2Y12 monotherapy (P2Y12) and dual antiplatelet therapy (DAPT) as compared to aspirin monotherapy (ASA) in the general peripheral arterial disease population, data in chronic limb-threatening ischemia (CLTI) patients is limited and ASA monotherapy continues to be widely prescribed. We aim to compare outcomes of ASA, P2Y12 and DAPT after lower extremity peripheral endovascular intervention (PVI) for CLTI. Patients undergoing index PVI for CLTI were identified from the Vascular Quality Initiative PVI registry. Propensity score matching was used to control for baseline differences in the groups. Kaplan-Meier and Cox regression analysis was used to compare limb salvage (LS), amputation-free survival (AFS) and overall survival (OS). A total of 12,433 index PVI in 11,528 patients were included. Antiplatelet use at follow-up was: 12% none, 31% ASA, 14% P2Y12, and 43% DAPT. Three-year LS was significant improved in DAPT (91.7%) group as compared to P2Y12 (89.4%) and ASA (86.8%) groups (P < .05) (Table). AFS was significantly improved in the DAPT (81.5%) and P2Y12 (79.6%) groups as compared to ASA (74.8%) (P < .05). Similarly, OS was significantly improved in the DAPT (88.9%) and P2Y12 (87.8%) groups as compared to ASA (85.5%) (P < .05). There were no significant differences between P2Y12 and DAPT in OS (P = .62) and AFS (P = .33); however, LS was significantly better in DAPT as compared to P2Y12 (P = .03). P2Y12 monotherapy and DAPT were associated with improved OS, AFS and LS as compared to ASA monotherapy in patients undergoing endovascular interventions for CLTI. P2Y12 monotherapy was superior to ASA monotherapy and comparable to DAPT in their survival and AFS benefit; however, LS was superior in DAPT. P2Y12 monotherapy may be considered in select CLTI patients.TableThree-year limb salvage (LS), amputation-free survival (AFS) and overall survival (OS) ratesASA versus P2Y12P valueP2Y12 versus DAPTP valueOS85.5 ± 1.0% vs 87.8 ± 0.9%.02687.8% ± 0.9% vs 88.9% ± 0.9%.62AFS74.8% ± 1.2% vs 79.6% ± 1.1%<.00179.6% ± 1.1% vs 81.5% ± 1.1%.33LS86.8% ± 0.9% vs 89.5% ± 0.8%.01389.5 ± 0.8% vs 91.7% ± 0.7%.03ASA, Aspirin; DAPT, dual antiplatelet therapy. Open table in a new tab