Longterm treatment of POAD with anticoagulants and platelet inhibitors after endovascular procedures and vascular surgery

H. Landgraf

doi:10.1055/s-0037-1617072

Hämostaseologie, Table of Contents

Hamostaseologie 2006; 26(03): 239-244
DOI: 10.1055/s-0037-1617072

Original Article

Schattauer GmbH

Nachbehandlung der pAVK nach Interventionen und Gefäßchirurgie mit Antikoagulanzien und Thrombozytenfunktionshemmern

Was ist gesichert?Longterm treatment of POAD with anticoagulants and platelet inhibitors after endovascular procedures and vascular surgeryWhat is evidence based?

H. Landgraf

¹Klinik für Innere Medizin – Angiologie und Hämostaseologie (Direktor: Prof. Dr. med. H. Landgraf), Zentrum für Gefäßmedizin, Vivantes-Klinikum im Friedrichshain, Berlin

› Author Affiliations

Abstract

PDF Download

Zusammenfassung

Sowohl nach Gefäßoperationen als auch katheterinterventionellen Eingriffen bei pAVK erfolgt in der Regel eine medikamentöse Nachbehandlung mit Thrombozytenfunktionshemmern bzw. Antikoagulanzien. Nur in Teilbereichen sind diese Therapien in Hinblick auf Effektivität (Offenheitsrate, Mortalität) und Sicherheit (Blutungskomplikationen) entsprechend evaluiert.

Eine ausreichend sichere Datenbasis gibt es nur für die Nachbehandlung von Prothesenbypässen mit Azetylsalizylsäure, in den übrigen Indikationen ist weder der Einsatz von Thrombozytenfunktionshemmern noch von Antikoagulanzien sicher belegt.

Die Empfehlung, Azetylsalizylsäure bei allen infrainguinalen Bypässen wie auch nach endovaskulären Katheterinterventionen dauerhaft einzusetzen, erfolgt vor allem auch unter dem Gesichtspunkt der Sekundärprophylaxe bei manifester arterieller Gefäßerkrankung.

Summary

Platelet inhibitors and anticoagulants are used in the longterm treatment after successful infrainguinal bypass grafts as well as endovascular revascularisation procedures. However, evidence of the usefulness of these therapies is limited with respect to efficiency (patency rate, mortality) and safety (bleeding tendency) concerning these indications. Sufficient data are only available for acetylsalicylic acid treatment after implantation of prosthetic bypass grafts, the data basis for the use of antithrombotic medication in venous bypass grafts or following successful balloon angioplasty with or without stent implantation is, however, inconclusive.

The recommendation for lifelong therapy with acetylsalicylic acid after infrainguinal bypass surgery and endovascular treatment is based mainly on the concept of prophylactic treatment of manifest atherosclerotic disease.

Schlüsselwörter

Thrombozytenfunktionshemmer - Antikoagulanzien - periphere arterielle Verschlusserkrankung - Gefäßchirurgie - Dilatation

Keywords

Platelet inhibitors - anticoagulants - peripheral arterial disease - vascular surgery - dilatation

PDF (385 kb)

References

Literatur
1 Antiplatelet Trialists` Collaboration.. Collaborative overview of randomized trials of antiplatelet therapy: II. Maintenance of vascular graft or arterial patency by antiplatelet therapy. Br Med J 1994; 308: 159-68.
2 Arfvidsson B, Lundgren F, Drott C. et al. Influence on coumarin treatment on patency and limb salvage after peripheral arterial reconstructive surgery. Am J Surg 1990; 159: 556-60.
3 Bhatt DL, Fox KAA, Hacke W. et al. Clopidogrel and Aspirin versus Aspirin alone for the prevention of atherothrombotic events. N Engl J Med 2006; 354: 1-12.
4 Becquemin JP. Effect of ticlopidine on the longterm patency of saphenous-vein bypass grafts in the legs. N Engl J Med 1997; 337: 1726-31.
5 Clagett GP, Sobel M, Jackson MR. et al. Antithrombotic therapy in peripheral arterial occlusive disease: The Seventh ACCP Conference on Antithrombotic and Thrombol Ther. Chest 2004; 126: 609-26.
6 Davies MG, Ilagen PO. Pathophysiology of vein graft failure: a review. Eur J Vasc Endovasc Surg 1995; 9: 7-18.
7 Do DD, Mahler F. Low-dose aspirin combined with dipyridamole versus anticoagulants after femoro- popliteal percutaneous transluminal angioplasty. Radiology 1994; 193: 567-71.
8 Dörffler-Melly J, Büller HR, Koopman MM. et al. Antiplatelet agents for preventing thrombosis after peripheral arterial bypass surgery. The Cochrane Database of Systematic Reviews 2003; 3.
9 Dörffler-Melly J, Büller HR, Koopman MMW. et al. Antithrombotic agents for preventing thrombosis after infrainguinal arterial bypass surgery. The Cochrane Database of Systematic Reviews 2003; 2.
10 Dörffler-Melly J, Koopman MMW, Prins MH. et al. Antiplatelet and anticoagulant drugs for prevention of restenosis/reocclusion following peripheral endovascular treatment. The Cochrane Database of Systematic Reviews 2005; 1.
11 Donaldson DR, Salter MC, Kester RC. et al. The influence of platelet inhibition on the patency of femoro-popliteal dacron bypass grafts. J Vasc Surg 1985; 19: 224-30.
12 Dutch Bypass Oral Anticoagulants or Aspirin (BOA) Study Group.. Efficacy of oral anticoagulants compared with aspirin after infrainguinal bypass surgery (The Dutch Bypass Oral Anticoagulants or Aspirin Study): a randomized trial. Lancet 2000; 355: 346-51.
13 Edmondson RA, Cohen AT, Das SK. et al. Lowmolecular weight heparin versus aspirin and dipyridamole after femoro-popliteal bypass grafting. Lancet 1994; 344: 914-8.
14 Goldman MD, McCollum CN. A prospective randomized study to examine the effect of aspirin plus dipyridamole on the patency of prosthetic femoro- popliteal grafts. J Vasc Surg 1984; 18: 217-21.
15 Girolami B, Bernardi E, Prins MH. et al. Antiplatelet therapy and other interventions after revascularization procedures in patients with peripheral arterial disease : a meta-analysis. Eur J Endovasc Surg 2000; 19: 370-80.
16 Green RM, Roedersheimer LR, DeWeese JA. Effects of aspirin and dipyridamole on expanded polytetrafluoroethylene graft patency. Surgery 1982; 92: 1016-26.
17 Hall P, Nakamura S, Maiello L. et al. A randomised comparison of combined ticlopidine and aspirin therapy versus aspirin therapy alone after successful intravascular ultrasound-guided stent implantation. Circulation 1996; 93: 215-22.
18 Heiss IIW, Just II, Middleton D. et al. Reocclusion prophylaxis with dipyridamole combined with acetylsalicylic acid following PTA. Angiology 1990; 41: 263-9.
19 Hirsch AT, Haskal ZJ, Hertzer NR. et al. ACC/ AHA Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic). J Am Coll Cardiol 2006; 47: 1239-312.
20 Jackson MR, Clagett GP. Antithrombotic therapy in peripheral arterial occlusive disease. Chest 2001; 119 suppl 283S-99S.
21 Johnson WC, Williford WO. Benefits, morbidity and mortality associated with peripheral arterial bypass procedures: a prospective randomized study. J Vasc Surg 2002; 35: 413-21.
22 Kohler TR, Kaufman JL, Kacoyanis GP. et al. Effect of aspirin and dipyridamole on the patency of lower extremity bypass grafts. Surgery 1984; 96: 462-6.
23 Kretschmer G, Herbst F, Prager M. et al. A decade of oral anticoagulant treatment of maintain autologous vein grafts for femoro-popliteal atherosclerosis. Arch Surg 1992; 127: 1112-5.
24 Kröger K. Postinterventionelle Behandlung nach peripheren Interventionen. VASA 2004; 33 (Suppl. 64) 73-9.
25 McCollum C, Alexander C, Kenchington G. et al. Antiplatelet drugs in femoropopliteal vein bypass: a multicenter trial. J Vasc Surg 1991; 13: 150-62.
26 Pfeffer MA, Jarcho JA. The charisma of subgroups and the subgroups of CHARISMA. N Engl J Med 2006; 353: 1-3.
27 Pilger E, Lammer J, Bertuch II. et al. Nd: Yag laser with sapphire tip combined with balloon angioplasty in peripheral arterial occlusions: long-term results. Circulation 1991; 83: 141-7.
28 Sarac TP, Huber TS, Back MR. et al. Warfarin improves the outcome of infrainguinal vein bypass grafting at high risk for failure. J Vasc Surg 1998; 28: 446-57.
29 Schneider E, Brunner U, Bollinger A. Medikamentöse Rezidivprophylaxe nach femoro-poplitealer Arterienrekonstruktion. Angiology 1979; 2: 73-7.
30 Schneider E, Mahler F, Do DD. et al. Zur Rezidivprophylaxe nach perkutaner transluminaler Angioplastie (PTA): Antikoagulation versus Ticlopidin. VASA 1987; 16 (Suppl. 20) 355-6.
31 Schömig A, Neumann FJ, Kastrati A. et al. A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary-artery stents. N Engl J Med 1996; 334: 1084-9.
32 Study Group on Pharmacological Treatment after PTA.. Platelet inhibition with ASA/dipyridamole after percutaneous balloon angioplasty in patients with symptomatic lower limb arterial disease: a prospective double-blind trial. Eur J Vasc Surg 1994; 8: 83-8.
33 Tangelder MJD, Algra A, Lawson JA. et al. Systematic review of randomized controlled trials of aspirin and oral anticoagulants in the prevention of graft occlusion and ischemic events after infrainguinal bypass surgery. J Vasc Surg 1999; 30: 701-9.
34 Tangelder MJD, Algra A, Lawson JA. et al. Optimal oral anticoagulant intensity to prevent secondary ischemic and hemorrhagic events in patients after infrainguinal bypass graft surgery. J Vasc Surg 2001; 33: 522-7.
35 Taylor DW, Barnett IIJM, Ilaynes RB. et al. Lowdose and high-dose acetylsalicylic acid for patients undergoing carotid endarterectomy: a randomized controlled trial. Lancet 1999; 353: 2179-84.
36 Watson HR, Bergquist D. Antithrombotic agents after peripheral transluminal angioplasty: a review of the studies, methods and evidence for their use. Eur J Endovasc Surg 2000; 19: 445-50.