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The following is a summary of “Variations in Antithrombotic Prescriptions and Evaluation of Extended Clopidogrel Therapy After Lower Extremity Revascularization for Peripheral Artery Disease,” published in the March 2025 issue of the Journal of Vascular Surgery and Research by Wells et al.

The optimal antithrombotic regimen and duration following lower extremity revascularization (LER) in patients with peripheral arterial disease (PAD) remain unclear, with significant variability in clinical practice. This study evaluates antithrombotic prescription patterns in a tertiary care center, emphasizing the challenges in standardizing treatment approaches. Specifically, the impact of clopidogrel therapy duration on patient outcomes was assessed. A retrospective review of electronic medical records identified patients with PAD who underwent LER, with pharmacists abstracting all antithrombotic prescriptions post-procedure. Demographic and clinical characteristics of patients prescribed clopidogrel were analyzed, and outcomes were compared between those receiving extended therapy (>12 months) and those with limited therapy (≤12 months). The study focused on major adverse limb events (MALE), major adverse cardiac events (MACE), and mortality. 

Among 1,954 patients, 17 different perioperative antithrombotic combinations were identified, expanding to 101 variations during long-term follow-up. Clopidogrel was the most frequently prescribed agent, used in 69.8% (N=1,363) of cases. Extended clopidogrel therapy was administered to 69.5% (N=947) of these patients. Those receiving extended therapy were more likely to have a history of prior endovascular procedures (21.8% vs 15.2%, P=0.005), whereas patients on limited therapy tended to be older (72 vs 69 years, P<0.001) and had higher rates of congestive heart failure (21% vs 14%, P=0.001) and chronic renal insufficiency (22.2% vs 15.6%, P=0.004). Patients on extended therapy were also more frequently treated for claudication (57.5% vs 46.1%, P<0.001), though revascularization strategies did not differ between groups. Kaplan-Meier survival analysis demonstrated significantly improved overall survival, MALE-free survival, and MACE-free survival in patients receiving extended clopidogrel therapy, though there was no significant difference in freedom from MALE or MACE. 

Cox regression analysis revealed an independent association between limited clopidogrel therapy and increased mortality (HR=1.93 [1.6-2.31]), mortality or MALE (HR=1.32 [1.14-1.53]), and mortality or MACE (HR=1.39 [1.2-1.62]). Importantly, extended clopidogrel therapy was not associated with an increased risk of bleeding. These findings highlight the substantial heterogeneity in antithrombotic prescribing practices after LER in patients with PAD and suggest that prolonged clopidogrel therapy may offer a survival benefit without elevating bleeding risk. However, the variability in prescription patterns underscores the limitations of observational studies, reinforcing the need for prospective randomized trials to establish evidence-based guidelines for antithrombotic therapy in PAD revascularization.

Source: jvascsurg.org/article/S0741-5214(25)00615-9/abstract