Impact of Dual Antiplatelet Therapy after Lower Extremity Revascularization for Chronic Limb Threatening Ischemia (CLTI)

Abstract Background The optimal antiplatelet regimen after lower extremity revascularization in patients with chronic limb threatening ischemia (CLTI) is unknown since current recommendations are based on extrapolation of data from trials in coronary artery disease and stroke. Methods We identified all patients undergoing an elective lower extremity revascularization for CLTI in the Vascular Quality Initiative registry discharged on a mono antiplatelet agent (MAPT) or dual antiplatelet therapy (DAPT). Results From 2003 to 2018, 50,890 patients underwent revascularization procedures for CLTI, and were discharged on MAPT or DAPT. Of these, 33,781 patients underwent endovascular therapy (EVT) and 17,109 patients underwent open surgery (OS) procedures. The rate of major amputation at 30 days in the target limb in the EVT group was 0.3% and 0.4% in the OS group (P=.22). On Kaplan Meier analyses, patients on MAPT at discharge had a higher risk 1-year major amputation compared to DAPT after EVT but not after OS procedures. Patients on MAPT had lower overall survival and amputation free survival (AFS) at 30 days and 1 year compared to DAPT after both EVT and OS. At 1 year, the MAPT group was at higher risk for target lesion re-intervention after EVT compared to the DAPT group (15.9% vs. 13%, P=.0012). There was no significant difference in thrombosis at 1 year between MAPT and DAPT groups either after EVT (3.9% vs. 3.7%; P=.3048) or OS (3.1% vs. 3.2%; P=.2893). On cox regression analysis, DAPT was associated with improved survival but not major amputation after both EVT and OS. Conclusions In CLTI patients, DAPT at the time of discharge has a positive impact on AFS and overall survival after both EVT and OS as well as target lesion re-intervention after EVT. DAPT was not associated with a positive impact on major amputation after either EVT or OS.