Prescribing Patterns of Antiplatelet Agents Are Highly Variable After Lower Extremity Endovascular Procedures

Abstract

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. 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. 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 81mg 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. 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.