Optimal Anticoagulation and Antiplatelet Therapy in Prosthetic Infrapopliteal Bypass

Antithrombotic agents are often prescribed following infrainguinal bypass. Few studies have compared patency or freedom from occlusion between dual antiplatelet (DAPT) and anticoagulation (AC) plus antiplatelet (AP) following prosthetic infrapopliteal bypass in the modern era where various antithrombotic regimens are available. This study aims to examine if DAPT vs AC+AP after prosthetic infrapopliteal bypass is associated with improved freedom from occlusion. A retrospective review of the Vascular Quality Initiative (VQI) Infrainguinal Bypass Database was conducted, analyzing patients undergoing procedures between 2003 and 2022. Inclusion criteria included adults over 18 years old with bypass graft inflow to the below-knee popliteal artery or distal with prosthetic conduit. Exclusion criteria included autologous vein conduit, prior revascularization, preoperative AC or DAPT. Not all comorbidities indicating patient needs for AC and AP are captured in VQI. Therefore, patients on preoperative therapy were excluded as a surrogate for new postoperative medication management aimed to support long-term bypass patency. AC was defined as warfarin or direct oral anticoagulants. AC+AP and DAPT groups were stratified based on medications prescribed after index bypass. Long-term freedom from occlusion and survival was assessed at 2 years post-procedure. Among 4228 patients identified, 54% (n = 2283) received AC+AP and 46.0% (n = 1945) received DAPT. There was a higher rate of Black patients receiving DAPT (20.4% vs 16.0%; P < .001). While age and hypertension were statistically different, they were not clinically significant (Table 1). Congestive heart failure rates were higher in AC+AP (25.% vs 21.3%; P = .005). More patients with any smoking history received DAPT (84.8% vs 81.9%; P = .009). Rates of chronic limb-threatening ischemia were higher in AC+AP (68.4% vs 62.8%; P < .001). Compared to patients receiving postoperative AC+AP, initiating postoperative DAPT had higher rates of freedom from occlusion (85.9 vs 81.3%; P < .001) (Fig 1) and overall survival (83.4 vs 80.9%; P = .02) at 2 years. In patients undergoing infrapopliteal bypass with prosthetic grafts, DAPT was associated with improved 2-year freedom from occlusion and overall survival than AC+AP. Given these results, initiating postoperative DAPT should be considered in prosthetic infrapopliteal bypass.TableDemographics and comorbidities of patients undergoing below-knee prosthetic bypassAC+AP(n = 2283)DAPT(n = 1945)P-valueAge, years69.88 ± 10.5868.99 ± 9.74.003Body mass index, kg/m227.35 ± 6.0226.87 ± 6.49.679Male sex1576 (69.0)1323 (68.0).454Black race365 (16.0)396 (20.4)<.001Hypertension2043 (89.5)1786 (91.8).007Coronary artery disease822 (36.0)755 (38.8).060Congestive heart failure571 (25.0)414 (21.3).005End-stage kidney disease199 (8.7)170 (8.7).974Diabetes mellitus1148 (50.3)1009 (51.9).294Smoking history1870 (81.9)1650 (84.8).009Current smoking789 (34.6)717 (36.9).113Chronic limb-threatening ischemia1561 (68.4)1222 (62.8)<.001Anticoagulants<.001 DOAC10740 (0.0) Warfarin12090 (0.0Antiplatelet sgents ASA1922 (84.2)1945 (100.0)<.001 P2Y2503 (22.0)1945 (100.0)<.001 Open table in a new tab