Antithrombotic Treatment for Peripheral Arterial Occlusive Disease.

BACKGROUND: Patients with peripheral arterial occlusive disease (PAOD) are at ele - vated risk for cardiovascular events and vascular events affecting the limbs. The goals of antithrombotic treatment are to keep vessels open after revascularization, to prevent cardiovascular events, and to lessen the frequency of peripheral ischemia and of amputation. METHODS: This review is based on pertinent publications retrieved by a selective literature search, with particular attention to meta-analyses, randomized controlled trials, and the German and European angiological guidelines. RESULTS: Diabetes mellitus and nicotine abuse are the main risk factors for lower limb PAOD. The evidence for the efficacy and safety of antithrombotic treatment in patients with PAOD is limited, in particular, after surgical or endovascular revascularization. Intensifying antithrombotic treatment with stronger antiplatelet therapy (APT), dual antiplatelet therapy (DAPT), or antiplatelet therapy combined with anticoagulation lowers the rate of peripheral revascularization (relative risk [RR] 0.89; 95% confidence interval [0.83; 0.94]), amputation (RR 0.63; [0.46; 0.86]), and stroke (RR 0.82; [0.70; 0.97]) but raises the risk of bleeding (RR 1.23; [1.04; 1.44]). Pre - dictors for peripheral vascular events include critical limb ischemia and having previously undergone a revascularization procedure or an amputation. CONCLUSION: Antiplatelet therapy should only be intensified for a limited time, or if the risk of ischemia is high. Before and during intensified antiplatelet therapy, the risk of bleeding should be assessed and weighed against the risk of ischemia. No validated score is available to estimate the risk of hemorrhagic complications in patients with PAOD. New antithrombotic therapies should not be used indiscriminately, but should rather be reserved for selected groups of patients.

[Dual Pathway Inhibition in Atherosclerosis - Which Patients Benefit?] / Dual-Pathway-Inhibition bei Atherosklerose ­ wer profitiert?

Dual antithrombotic therapy (DAT) with low-dose rivaroxaban in combination with acetylsalicylic acid (ASA) is available to patients with stable atherosclerotic disease as a new therapeutic option.The results of the COMPASS trial demonstrate a significant relative risk reduction of cardiovascular outcomes by 24 % with low-dose DAT in patients with stable peripheral arterial disease or coronary heart disease.Despite a guideline adherent secondary prevention therapy, the cardiovascular event rate with ASA alone during the mean study period of almost two years was 5.4 %. The absolute reduction of the event rate by the low-dose DAT is low at 1.3 %. Consequently, it is important to identify groups of patients at high risk for cardiovascular events. These patients are particularly qualified to receive a DAT regimen and can be characterized using high-risk features.The individual ischemic risk profile may be further defined by the presence of polyvascular atherosclerosis, concomitant diseases, and ischemic events in the past. The quo ad vitam reduced prognosis of patients with polyvascular atherosclerosis advocates a polyvascular screening, even in supposedly stable patients with coronary heart disease and peripheral arterial disease.An intensification of antithrombotic therapy is naturally associated with an increased risk of bleeding. Therefore, the risk-reduction of ischemic events should be weighed individually against the risk of bleeding.A low-dose DAT is particularly suitable for patients with a high ischemic risk and a low risk of bleeding.

Real-world outcomes of endovascular treatment in a non-selected population with peripheral artery disease - prospective study with 2-year follow-up.

Background: The study aimed to evaluate the outcomes of percutaneous transluminal angioplasty (PTA) in lower-extremity peripheral artery disease (PAD) patients. Patients and methods: A multi-centre, observational study was performed with 32 German and Austrian centres contributing data to the PTA registry. Data of 1,781 patients with lower-leg and pelvic PAD who were suitable for endovascular PTA treatment were contributed from participating centres. Data from 1,533 patients are reported here (1,055 male and 478 female). This study did not have exclusion criteria. Quality of life (QOL) questionnaire (EQ-5D) scores, Rutherford classification, mortality, patency rate and details of major adverse cardiovascular events were collected at 6-, 12-, 18-, and 24-month follow ups. Results: PTA with/without stenting achieved 90.3 %, 86.5 %, 82.7 %, and 71.9 % technical success (recanalisation achieving ≥ 70 % patency, no evidence of embolisation, recoiling or dissection) in iliac, femoral, popliteal, and below-the-knee arteries, respectively. Procedural/postprocedural complications occurred in 142 (9.3 %, 1 death) and 74 (4.8 %) patients. QOL, mobility, self-care, activity, and pain/discomfort scores improved (p < 0.01), anxiety/depression was insignificantly improved. During follow-up, 409 (26.7 %) patients were hospitalised for PAD, 281 (18.3 %) required reintervention, and 145 (9.5 %) died or needed amputation (n = 49; 3.2 %). Multivariate analysis demonstrated poorer outcomes in patients with comorbidities. Conclusions: PTA with/without stenting is effective, safe, and widely applicable, with few complications. It improves QOL, but not anxiety/depression.

Post mortem analysis of a left atrial appendage occlusion device (PLAATO) in a patient with permanent atrial fibrillation.

Thromboemoblism is the most feared complication of atrial fibrillation. Percutaneous left atrial appendage occlusion is a new interventional procedure for reducing thromboembolic risk in patients with atrial fibrillation. The paper reports of a post mortem analysis of the device demonstrating that one year after implantation the atrial surface of the device is completely covered by neo-endothelium and the device occludes the appendage completely.

Mechanical occlusion of the left atrial appendage.

INTRODUCTION: Oral anticoagulation therapy reduces significantly the risk of thromboembolism in patients with atrial fibrillation. However, effective oral anticoagulation therapy is not feasible in all patients. The interventional occlusion of the left atrial appendage may reduce the risk of thromboembolism in the latter patients. The aim of this prospective study was to assess the feasibility, safety, and technical aspects of interventionally occluding the left atrial appendage. METHODS AND RESULTS: The left atrial appendage was interventionally occluded with the new PLAATO device in nine patients. Serial transthoracic and transesophageal echocardiographic studies and neurologic assessment were performed prior to and during the procedure, and <48 hours, 3 months, 6 months, and 1 year after the procedure. Contraindications to oral anticoagulation were bleeding complications in 6 of 9 cases, cerebral aneurysm in 1, and allergies to warfarin therapy in 2 of 9. Baseline echocardiographic studies demonstrated spontaneous echo contrast grade 3 +/- 1, peak emptying velocities of 0.26 +/- 0.12 m/sec, and excluded atrial thrombi in all cases. Interventional occlusion was feasible in all cases. One patient had a minor plexus paresis that resolved within 4 weeks after the procedure. Neurologic assessment during a mean follow-up of 5 +/- 4.4 months did not demonstrate any new neurologic complications. Serial echocardiographic assessment excluded the formation of thrombi on the implanted device and demonstrated its complete thrombosis after 6 months. One patient developed a minimal pericardial effusion 48 hours after the procedure that resolved within 3 months. CONCLUSION: Interventional occlusion of the left atrial appendage is feasible and safe in patients with atrial fibrillation and contraindications to oral anticoagulation therapy. Furthermore, no neurologic complications, development of atrial thrombi, or thrombus formation on the device were observed during follow-up. Future prospective studies are needed to clarify the long-term treatment effect of this new technique.