Antithrombotic Therapy After Lower Limb EndoVascular Interventions: Are We Overtreating or Undertreating? – A Narrative Review

Peripheral arterial disease patients undergoing lower limb revascularization remain at high risk of thrombotic complications, yet optimal postprocedural antithrombotic therapy remains uncertain. Current strategies vary widely, reflecting the difficulty of balancing ischemic protection against bleeding risk. This review critically examines the evidence supporting antithrombotic approaches after lower limb revascularization and explores whether contemporary practice is characterized by overtreatment, undertreatment, or both. Randomized controlled trials, subgroup analyses, and recent meta-analyses evaluating dual pathway inhibition (DPI), dual antiplatelet therapy (DAPT), and single antiplatelet therapy were reviewed, with particular attention to efficacy, safety, treatment duration, and patient selection. DPI is supported by robust randomized evidence demonstrating reductions in major adverse cardiovascular and limb events, particularly after revascularization. In contrast, DAPT remains widely used despite limited and methodologically heterogeneous evidence. Available meta-analyses suggest potential reductions in myocardial infarction, cardiac mortality, and reintervention with DAPT compared with single antiplatelet therapy, although certainty remains low and no randomized trial has directly compared DAPT with DPI. This evidentiary gap contributes to a clinical paradox in which some patients receive prolonged combination therapy with excess bleeding risk, whereas others at particularly high ischemic risk may remain undertreated. Current guideline-based approaches insufficiently account for procedural complexity, patient phenotype, and temporal changes in thrombotic risk. A more personalized and dynamic antithrombotic strategy is needed to optimize outcomes in peripheral arterial disease after revascularization.