Antiplatelet Therapy for Peripheral Arterial Disease and Critical Limb Ischemia

Azarbal, Amir F.; Clavijo, Leonardo; Gaglia, Michael A.

doi:10.1177/1074248414545126

Cited by 16 publications

(14 citation statements)

References 71 publications

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“…It is estimated that 15 % of patients with PAD will eventually require lower limb amputation due to acute limb ischemia, which occurs when viability of the limb is threatened by a sudden reduction in perfusion [40]. Patients with CLI benefit from life-long antiplatelet therapy, yet only a minority of patients with CLI have been included in prospective clinical trials investigating cilostazol [41]. Cilostazol has been identified as an independent predictor of reduced restenosis, re-occlusion, and TLR in patients with CLI 3 months after FP angioplasty in a retrospective analysis [42].…”

Section: Critical Limb Ischemiamentioning

confidence: 99%

Clinical Efficacy and Safety of Cilostazol: A Critical Review of the Literature

Rogers

Oliphant

Finks

2015

Drugs

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Cilostazol is a unique antiplatelet agent that has been commercially available for over two decades. As a phosphodiesterase III inhibitor, it reversibly inhibits platelet aggregation yet also possesses vasodilatory and antiproliferative properties. It has been widely studied in a variety of disease states, including peripheral arterial disease, cerebrovascular disease, and coronary artery disease with percutaneous coronary intervention. Overall, cilostazol appears to be a promising agent in the management of these disease states with a bleeding profile comparable to placebo; even when combined with other antiplatelet agents, cilostazol does not appear to increase the rate of bleeding. Despite the possible benefit of cilostazol, its use is limited by tolerability as some patients often report drug discontinuation due to headache, diarrhea, dizziness, or increased heart rate. To date, it has been predominantly studied in the Asian population, making it difficult to extrapolate these results to a more diverse patient population. This paper discusses the evolving role of cilostazol in the treatment of vascular diseases.

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Section: Critical Limb Ischemiamentioning

confidence: 99%

Clinical Efficacy and Safety of Cilostazol: A Critical Review of the Literature

Rogers

Oliphant

Finks

2015

Drugs

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“…The Society for Vascular Surgery recommends a minimum of 30 days of aspirin and clopidogrel following infrainguinal endovascular procedures (grade 2B) [19, 41]. The consensus across the majority of the studies, however, is that there is a lack of evidence to support one specific treatment regimen [19–22, 26, 27].…”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

“…CLI-specific antiplatelet/anticoagulant therapy is mainly extrapolated from studies of patients with asymptomatic PAD or claudication [27, 47]. Azarbal et al suggested the extrapolation of PAD to CLI is reasonable since the studies contain both PAD and CLI patients [27]; however, there are challenges with this extrapolation. For instance, the efficacy of aspirin in patients with CLI remains elusive and may be related to underrepresentation of CLI in clinical trials of PAD, inefficient aspirin metabolism (i.e., aspirin resistance), and inappropriate dosing [27, 48].…”

Section: Discussionmentioning

confidence: 99%

“…The majority of published reviews focus on evaluating antithrombotic treatment for PAD in general and are not specific to CLI [19–25]. Additionally, few studies were specifically dedicated to CLI but instead were non-comprehensive and included a mixture of CLI and claudication patients [26, 27]. This may be due to the lack of reliable data regarding antithrombotic therapy for CLI following endovascular procedures because most studies are not stratified by the presence of CLI and may lack standardized follow-up procedures.…”

Section: Introductionmentioning

confidence: 99%

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A Review of Antithrombotic Treatment in Critical Limb Ischemia After Endovascular Intervention

et al. 2019

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Endovascular intervention is often used to treat critical limb ischemia (CLI). Post-intervention treatment with antiplatelet and/or anticoagulant therapy has reduced morbidity and mortality due to cardiovascular complications. The purpose of this review is to shed light on the various pharmacologic treatment protocols for treating CLI following endovascular procedures. We reviewed the literature comparing outcomes after antithrombotic treatment for patients with CLI. We characterized antithrombotic therapies into three categories: (1) mono-antiplatelet therapy (MAPT) vs. dual antiplatelet therapy (DAPT), (2) MAPT vs. antiplatelet (AP) ? anticoagulant (AC) therapy, and (3) AC vs. AP ? AC therapy. Relevant results and statistics were extracted to determine differences in the rates of the following outcomes: (1) re-stenosis, (2) occlusion, (3) target limb revascularization (TLR), (4) major amputation, (5) major adverse cardiac events, (6) all-cause death, and (7) bleeding. Studies suggest that DAPT reduces post-surgical restenosis, TLR, and amputation for diabetic patients, without increasing major bleeding incidences, compared to MAPT. Also, AP ? AC therapy provides overall superior efficacy, with no difference in bleeding incidences, compared to antiplatelet alone. Additionally, the effects were significant for restenosis, limb salvage, survival rates, and cumulative rate of above ankle amputation or death. These results suggest that treatment with DAPT and AP ? AC might provide better outcomes than MAPT following the endovascular intervention for CLI, and that the ideal treatment may be related to the condition of the individual patient. However, the studies were few and heterogenous with small patient populations. Therefore, further large controlled studies are warranted to confirm these outcomes.

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Combination Therapy with Dipyridamole and Clopidogrel for Secondary Stroke Prevention in Aspirin-Intolerant Patients After Myocardial Infarction: Results of a Nationwide Case-Control Study

et al. 2019

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Background and Purpose Combination therapy with dipyridamole and clopidogrel in stroke prevention and long-term outcomes in aspirin-intolerant patients with acute myocardial infarction (AMI) and previous stroke are unknown. This nationwide study analyzed the impact of dipyridamole and clopidogrel on secondary stroke prevention and long-term outcomes in aspirin-intolerant stroke patients after AMI. Methods This was a nationwide, case-control study involving 186,112 first AMI patients, 78,607 of whom had a previous history of stroke. In the final analysis, we included 4637 patients taking clopidogrel alone and 208 patients using a combination of clopidogrel and dipyridamole. Results The 12-year survival rate was not different between clopidogrel and clopidogrel–dipyridamole groups (log-rank p = 0.6247). Furthermore, there were no differences in event-free survival after stroke (log-rank p = 0.6842), gastrointestinal (GI) bleeding (log-rank p = 0.9539), or intracerebral hemorrhage (ICH; log-rank p = 0.6191) between the two groups. Dipyridamole did not contribute significantly to AMI survival (hazard ratio 0.98, 95% confidence interval 0.84–1.15), and did not show benefits in any of the subgroups regardless of sex, age (younger or older than 75 years), comorbidities, percutaneous coronary intervention, or medications. Conclusion No differences were observed in the 12-year survival rate between clopidogrel and clopidogrel–dipyridamole groups. The two groups had balanced event-free survival in recurrent stroke, ICH, GI bleeding, and myocardial infarction.

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Antiplatelet Therapy for Peripheral Arterial Disease and Critical Limb Ischemia

Cited by 16 publications

References 71 publications

Clinical Efficacy and Safety of Cilostazol: A Critical Review of the Literature

Clinical Efficacy and Safety of Cilostazol: A Critical Review of the Literature

A Review of Antithrombotic Treatment in Critical Limb Ischemia After Endovascular Intervention

Combination Therapy with Dipyridamole and Clopidogrel for Secondary Stroke Prevention in Aspirin-Intolerant Patients After Myocardial Infarction: Results of a Nationwide Case-Control Study

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