Allemang Matthew T, Rajani Ravi R, Nelson Peter R, Hingorani Anil, Kashyap Vikram S
Division of Vascular & Endovascular Therapy, University Hospitals Case Medical Center, Cleveland, OH 44106, USA.
Ann Vasc Surg. 2013 Jan;27(1):62-7. doi: 10.1016/j.avsg.2012.05.001. Epub 2012 Sep 12.
The use of antiplatelet and antithrombotic agents after peripheral vascular interventions is a common clinical practice despite a lack of clear convincing evidence or accepted practice guidelines. The goal of this study was to assess surgeons' prescribing practices after endovascular procedures for lower extremity arterial occlusive disease.
Attendees at a national vascular meeting were asked to complete a voluntary survey indicating their prescribing practices of antiplatelet/antithrombotic agents for the following procedures: iliac bare-metal stent, iliac covered stent, infrainguinal balloon angioplasty, infrainguinal bare-metal stent, infrainguinal covered stent, infrainguinal atherectomy, and lower extremity cryoplasty. The respondents were given choices of aspirin (ASA) alone, clopidogrel alone, ASA/clopidogrel combined, warfarin alone, or ASA/clopidogrel/warfarin combined. They were also asked to indicate their preferred length of treatment for each medication or combination of medications for each procedure: 1, 3, 6, or 12 months.
There were 51 respondents (48 vascular surgeons and 3 vascular fellows) with an average of 11 ± 6.4 years of experience and practicing in a university hospital (48%), community hospital (44%), or combined university/Veterans A hospital (6%) setting. The majority of respondents (98%) prescribe an antiplatelet agent for patients with peripheral arterial disease using 81 mg of ASA preferentially. Most surgeons do not obtain genetic testing (i.e., cytochrome P450, polypeptide 19 [CYP2C19] polymorphism) for antiplatelet effectiveness. The most common antiplatelet/antithrombotic medication of choice after lower extremity endoluminal therapy was a combination of ASA/clopidogrel. However, the duration of medical treatment was variable, with a 1- to 3-month course being the most common. The use of the ASA/clopidogrel combination increased with further distal endovascular treatment and the placement of stents versus angioplasty. In the vast majority of ASA-only responses, ASA was administered for at least 12 months if not recommended for life. Although the majority of surgeons would recommend dual antiplatelet therapy (52-77%), there was no consensus regarding the duration of treatment.
The antiplatelet/antithrombotic prescribing practices of vascular surgeons after lower extremity endovascular procedures are highly variable. Multicenter randomized controlled trials are needed to define optimal treatment efficacy and define the much-needed practice guidelines.
尽管缺乏明确令人信服的证据或公认的实践指南，但在周围血管介入治疗后使用抗血小板和抗血栓药物是一种常见的临床做法。本研究的目的是评估外科医生在下肢动脉闭塞性疾病血管内手术后的处方习惯。
要求参加全国血管会议的与会者完成一项自愿调查，表明他们在以下手术中使用抗血小板/抗血栓药物的处方习惯：髂动脉裸金属支架置入术、髂动脉覆膜支架置入术、腹股沟下球囊血管成形术、腹股沟下裸金属支架置入术、腹股沟下覆膜支架置入术、腹股沟下斑块旋切术和下肢冷冻球囊血管成形术。受访者可选择单独使用阿司匹林（ASA）、单独使用氯吡格雷、ASA/氯吡格雷联合使用、单独使用华法林或ASA/氯吡格雷/华法林联合使用。他们还被要求指出每种手术中每种药物或药物组合的首选治疗时长：1个月、3个月、6个月或12个月。
共有51名受访者（48名血管外科医生和3名血管外科住院医师），平均从业经验为11±6.4年，工作于大学医院（48%）、社区医院（44%）或大学/退伍军人医院联合机构（6%）。大多数受访者（98%）优先为外周动脉疾病患者开具81毫克ASA的抗血小板药物。大多数外科医生未进行抗血小板疗效的基因检测（即细胞色素P450，多肽19 [CYP2C19]多态性检测）。下肢腔内治疗后最常用的抗血小板/抗血栓药物是ASA/氯吡格雷联合使用。然而，药物治疗时长各不相同，最常见的疗程为1至3个月。随着血管内治疗部位进一步向远端以及与血管成形术相比支架置入术的应用，ASA/氯吡格雷联合使用的情况增多。在绝大多数仅使用ASA的回复中，如果未建议终身服用，ASA至少服用12个月。尽管大多数外科医生会推荐双联抗血小板治疗（52 - 77%），但在治疗时长方面未达成共识。
血管外科医生在下肢血管内手术后的抗血小板/抗血栓处方习惯差异很大。需要进行多中心随机对照试验来确定最佳治疗效果并制定急需的实践指南。
