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The best method of anticoagulation for patients with peripheral artery disease (PAD) is still a topic of interest for physicians. We conducted a meta-analysis to compare the effects of direct oral anticoagulants (DOACs) with those of vitamin-K-antagonist (VKA) anticoagulants in patients with peripheral artery disease. Five databases (Medline (via PubMed), EMBASE, Scopus, Web of Science, and CENTRAL) were searched systematically for studies comparing the effects of the two types of anticoagulants in patients with PAD, with an emphasis on lower-limb outcomes, cardiovascular events, and mortality. In PAD patients with concomitant non-valvular atrial fibrillation (NVAF), the use of DOACs significantly reduced the risk of major adverse limb events (HR = 0.58, 95% CI, 0.39–0.86, p < 0.01), stroke/systemic embolism (HR 0.76; 95% CI 0.61–0.95; p < 0.01), and all-cause mortality (HR 0.78; 95% CI 0.66–0.92; p < 0.01) compared with warfarin, but showed similar risks of MI (HR = 0.81, 95% CI, 0.59–1.11, p = 0.2) and cardiovascular mortality (HR = 0.77, 95% CI, 0.58–1.02, p = 0.07). Rivaroxaban at higher doses significantly increased the risk of major bleeding (HR = 1.16, 95% CI, 1.07–1.25, p < 0.01). We found no significant difference in terms of revascularization (OR = 1.49, 95% CI, 0.79–2.79, p = 0.14) in PAD patients in whom a poor distal runoff was the reason for the anticoagulation. DOACs have lower rates of major limb events, stroke, and mortality than VKAs in PAD patients with atrial fibrillation. Rivaroxaban at higher doses increased the risk of major bleeding compared with other DOAC drugs. More high-quality studies are needed to determine the most appropriate anticoagulation regimen for patients with lower-limb atherosclerosis.

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Összefoglaló. Bevezetés: A diffúz aortobiiliacalis érszakasz occlusiv betegségének kezelésére alkalmazott aortobifemoralis bypass szerepe csökken az endovascularis műtétek térnyerése miatt. Célkitűzés: A vizsgálat célja volt a modern invazív kezelés korszakában a perioperatív és a hosszú távú eredmények elemzése aortobiiliacalis bypass után, melyek összehasonlíthatók az endovascularis megoldások eredményeivel. Módszerek: A retrospektív, egycentrumú vizsgálat során a Semmelweis Egyetem Városmajori Szív- és Érgyógyászati Klinikájának Érsebészeti és Endovaszkuláris Tanszékén 2006. 01. 01. és 2017. 12. 31. között occlusiv aortoiliacalis atherosclerosis miatt primer aortobifemoralis bypass műtéten átesett 419 beteg (átlagéletkor: 62,2 év, SD: ± 8,22; 224 férfi, 53%) adatait elemeztük. Eredmények: A posztoperatív 30 napon belüli mortalitás 5,01%, a késői mortalitás 10,98% és 29,59% volt 12, illetve 60 hónap után. A betegek 12,57%-ánál történt korai reoperáció, késői reoperáció 32 (8%) betegnél vált szükségessé. A graft elsődleges nyitva maradása 88,65% és 81,15% volt 12, illetve 60 hónap után. 21 betegnél történt amputáció (6,29%); 57,14%-ban femoralis, 35,71%-ban cruralis szinten, 7,14%-ban a boka szintje alatt. Az amputációkra 35,71%-ban a bypasst követő 30 napon belül, további 35,71%-ban 2 éven belül került sor. Az esetek 35,63%-ában lépett fel egyéb szövődmény; a leggyakoribbak: műtétet igénylő posztoperatív hernia (6,89%), cardiovascularis szövődmény (4,19%), lágyéki nyirokcsorgás vagy sebgyógyulási zavar (4,79%). Következtetés: Eredményeink alapján e betegcsoportban az aortobifemoralis bypass elfogadható, de nem jelentéktelen perioperatív halálozással és magas morbiditással jár. A graft hosszú távú nyitva maradása jó, de az újabb érműtét mind rövid, mind hosszú távon relatíve gyakori. A kevésbé invazív technikák eredményeinek összehasonlítása indokolt a hosszú szakaszú (TASC C, D) elváltozások esetén. Orv Hetil. 2021; 162(3): 99–105. Summary. Introduction: The role of aorto-bifemoral bypass in the treatment of diffuse aorto-biiliac occlusive disease decreases in the era of endovascular surgery. Objective: The aim of the study was to analyse the early and long-term postoperative results of aorto-bifemoral bypass in a recent time period. These results may be used as a baseline to compare the results of endovascular procedures. Methods: In a retrospective, single-center study, the data of 419 patients (mean age: 62.2 years, SD: ± 8.22; 224 men, 53%) who underwent primary aorto-bifemoral bypass due to occlusive aorto-iliac atherosclerosis from 01. 01. 2006 to 31. 12. 2017 at the Department of Vascular and Endovascular Surgery of Semmelweis University Heart and Vascular Center were analysed. Results: Postoperative mortality within 30 days was 5.01%, late mortality was 10.98% and 29.59% after 12 and 60 months, respectively. 12.57% of the patients needed early reoperation and late reoperation was required in 32 cases (8%). The primary graft patency was 88.65% and 81.15% after 12 and 60 months, respectively. 21 patients underwent amputation (6.29%); 57.14% at the femoral level, 35.71% at the crural level and 7.14% below the ankle level. Amputations were performed in 35.71% of the cases within 30 days after the bypass and an additional 35.71% within 2 years. Other complications occurred in 35.63% of the cases; the most common causes were postoperative hernia requiring surgery (6.89%), cardiovascular complication (4.19%) and inguinal wound healing disorders (4.79%). Conclusion: Based on our results, aorto-bifemoral bypass surgery is associated with acceptable but not insignificant perioperative mortality and high morbidity in this group of patients. The graft patency is favourable in the long term, however, additional vascular reintervention is common in short and long term as well. Short- and long-term results of percutaneous endovascular techniques in diffuse aorto-biiliac disease (TASC C and D lesions) are suggested to be compared to these recent results of open surgery. Orv Hetil. 2021; 162(3): 99–105.

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