De Carlo Marco, Schlager Oliver, Mazzolai Lucia, Brodmann Marianne, Espinola-Klein Christine, Staub Daniel, Aboyans Victor, Sillesen Henrik, Debus Sebastian, Venermo Maarit, Belch Jill, Ferrari Mauro, De Caterina Raffaele
Cardiothoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, 56124 Pisa, Italy.
Division of Angiology, 2nd Department of Medicine, Medical University of Vienna, 1090 Vienna, Austria.
Eur Heart J Cardiovasc Pharmacother. 2023 Apr 10;9(3):201-207. doi: 10.1093/ehjcvp/pvac055.
Chronic limb-threatening ischaemia (CLTI) entails dismal outcomes and is an absolute indication to lower extremity revascularization (LER) whenever possible. Antithrombotic therapy is here crucial, but available evidence on best strategies (choice of drugs, combinations, duration) is scarce. We conducted a European internet-based survey on physicians' use of antithrombotic therapy after revascularization for CLTI, under the aegis of the ESC Working Group on Aorta and Peripheral Vascular Disease in collaboration with other European scientific societies involved in CLTI management and agreeing to send the survey to their affiliates.
225 respondents completed the questionnaire. Antithrombotic therapy following surgical/endovascular LER varies widely across countries and specialties, with dedicated protocols reported only by a minority (36%) of respondents. Dual antiplatelet therapy with aspirin and clopidogrel is the preferred choice for surgical (37%) and endovascular (79%) LER. Dual pathway inhibition (DPI) with aspirin and low-dose rivaroxaban is prescribed by 16% of respondents and is tightly related to the availability of reimbursement (OR 6.88; 95% CI 2.60-18.25) and to the choice of clinicians rather than of physicians performing revascularization (OR 2.69; 95% CI 1.10-6.58). A ≥ 6 months-duration of an intense (two-drug) postprocedural antithrombotic regimen is more common among surgeons than among medical specialists (OR 2.08; 95% CI 1.10-3.94). Bleeding risk assessment is not standardised and likely underestimated.
Current antithrombotic therapy of CLTI patients undergoing LER remains largely discretional, and prescription of DPI is related to reimbursement policies. An individualised assessment of thrombotic and bleeding risks is largely missing.
慢性肢体威胁性缺血（CLTI）预后不佳，是尽可能进行下肢血运重建（LER）的绝对指征。抗栓治疗在此至关重要，但关于最佳策略（药物选择、联合用药、疗程）的现有证据匮乏。我们在欧洲心脏病学会主动脉和外周血管疾病工作组的支持下，与其他参与CLTI管理并同意将调查发送给其附属机构的欧洲科学学会合作，开展了一项基于互联网的针对CLTI血运重建术后医生抗栓治疗使用情况的调查。
225名受访者完成了问卷。手术/血管腔内LER后的抗栓治疗在不同国家和专业之间差异很大，只有少数（36%）受访者报告有专门的方案。阿司匹林和氯吡格雷的双联抗血小板治疗是手术（37%）和血管腔内（79%）LER的首选。16%的受访者使用阿司匹林和低剂量利伐沙班的双途径抑制（DPI），这与报销政策的可用性密切相关（比值比6.88；95%置信区间2.60 - 18.25），并且与临床医生而非进行血运重建的医生的选择有关（比值比2.69；95%置信区间1.10 - 6.58）。术后强化（两种药物）抗栓方案持续≥6个月在外科医生中比在内科医生中更常见（比值比2.08；95%置信区间1.10 - 3.94）。出血风险评估未标准化且可能被低估。
目前接受LER的CLTI患者的抗栓治疗在很大程度上仍是随意的，DPI的处方与报销政策有关。对血栓形成和出血风险的个体化评估在很大程度上缺失。
