Clinical Practice Recommendations for Antithrombotic Management of Peripheral Artery Disease: An Indian Perspective

Abstract

Currently, there are no guidelines or consensus recommendations on the antithrombotic management of peripheral artery disease (PAD) from an Indian perspective. In this article, we have summarized clinical practice recommendations on antithrombotic management of (i) asymptomatic chronic PAD (cPAD), (ii) symptomatic cPAD (intermittent claudication [IC] and chronic limb-threatening ischemia [CLTI]), and (iii) after revascularization (endovascular and surgical). An electronic search of the PubMed database was undertaken to identify relevant articles. Various combinations of keywords such as PAD, chronic peripheral arterial disease, asymptomatic chronic peripheral arterial disease, symptomatic chronic peripheral arterial disease, dual antiplatelet therapy, single antiplatelet therapy, dual pathway inhibition, antithrombotic, revascularization, endovascular, and surgical were used. Randomized controlled trials, case reports, practice guidelines, systematic literature reviews, and meta-analyses were screened and assessed. A roundtable meeting of experts (n = 13) was conducted to arrive at clinical practice recommendations. Experts made their decisions based on the evidence and guideline recommendations. In patients with asymptomatic cPAD and significant peripheral artery stenosis (PAS), long-term single antiplatelet therapy may be considered at the discretion of the clinician. There is no clear evidence in favor of long-term dual antiplatelet therapy in symptomatic cPAD. Experts agreed that low-dose rivaroxaban plus aspirin should be considered in patients with asymptomatic cPAD with >50% PAS and conditions such as diabetes and polyvascular disease. This combination was also suggested in patients with IC, CLTI, postendovascular (stent based/nonstent), and surgical revascularization to reduce cardiovascular and limb ischemic risk, including major amputation in the absence of high bleeding risk or other contraindications.