Antithrombotic therapies in aortic and peripheral arterial diseases in 2021: a consensus document from the ESC working group on aorta and peripheral vascular diseases, the ESC working group on thrombosis, and the ESC working group on cardiovascular pharmacotherapy

Abstract

The aim of this collaborative document is to provide an update for clinicians on best antithrombotic strategies in patients with aortic and/or peripheral arterial diseases. Antithrombotic therapy is a pillar of optimal medical treatment for these patients at very high cardiovascular risk. While the number of trials on antithrombotic therapies in patients with aortic or peripheral arterial diseases is substantially smaller than for those with coronary artery disease, recent evidence deserves to be incorporated into clinical practice. In the absence of specific indications for chronic oral anticoagulation due to concomitant cardiovascular disease, a single antiplatelet agent is the basis for long-term antithrombotic treatment in patients with aortic or peripheral arterial diseases. Its association with another antiplatelet agent or low-dose anticoagulants will be discussed, based on patient’s ischaemic and bleeding risk as well therapeutic paths (e.g. endovascular therapy). This consensus document aims to provide a guidance for antithrombotic therapy according to arterial disease localizations and clinical presentation. However, it cannot substitute multidisciplinary team discussions, which are particularly important in patients with uncertain ischaemic/bleeding balance. Importantly, since this balance evolves over time in an individual patient, a regular reassessment of the antithrombotic therapy is of paramount importance.

Managing thrombotic risk in patients with diabetes

“…Based on these results, specific recommendation updates have been included in the European label for rivaroxaban for vascular dose rivaroxaban plus low-dose aspirin for the prevention of atherothrombotic events in patients with symptomatic PAD at high risk of ischaemic events, to include those with a recent lower-extremity revascularization or diabetes [ 53 ]. Guidelines now recommend dual pathway inhibition with rivaroxaban 2.5 mg bid plus aspirin 100 mg od in patients with symptomatic PAD undergoing peripheral revascularization and should be considered following peripheral revascularization in patients with symptomatic PAD without an increased bleeding risk [ 54 , 55 ].…”

Antithrombotic therapy in peripheral arterial disease

“…Antiplatelet drugs reduce the occurrence of cardiovascular events in PAD and have a high level of recommendation in current guidelines ( 2 , 3 , 26 , 27 ). The Antithrombotic Trialists' Collaboration Collaborative published a meta-analysis of randomized trials including antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high-risk patients.…”

“…Patients with PAD had higher thrombotic risk and greater advantage from more intensive antithrombotic medication ( 32 ). Therefore, recent guidelines recommend the combination of ASA and low rivaroxaban especially for patients with high risk for cardiovascular events and low bleeding risk ( 26 , 27 ).…”

Editor's Choice – PRINciples of optimal antithrombotiC therapy and coagulation managEment during elective fenestrated and branched EndovaScular aortic repairS (PRINCE2SS): An International Expert Based Delphi Consensus Study

“…13e17 Thus far antithrombotic management has been left to the individual centres or physicians, and details are inconsistently reported in F-BEVAR studies. 15 By designing an international expert based Delphi consensus, the study aimed: 1) to investigate the practices endorsed at high volume aortic centres; 2) to create recommendations on pre-, intra-, and post-operative management of antithrombotic therapy in patients scheduled for elective F-BEVAR of complex AAAs and/or TAAAs; and 3) to highlight areas of uncertainty that would benefit from future research.…”