Selective Use of Anticoagulation or Dual Antiplatelet Therapy for Patients with Extra-Anatomic Bypasses.

OBJECTIVES: The benefit of long-term anticoagulation or dual antiplatelet therapy (DAPT) for patients with extra-anatomic bypasses to the lower extremity remains poorly defined. Our study analyzed the real-world use of antithrombotic therapy in patients with extra-anatomic bypass grafts to the lower extremity and compared graft and patient outcomes by antithrombotic regimen. METHODS: We studied patients who underwent axillo-femoral or femoral-femoral bypass within the Vascular Quality Initiative (VQI) with one-year follow-up data. Primary exposures were anticoagulation and DAPT, at the time of index procedure and one-year follow-up. Primary outcomes were major adverse limb events (MALE) defined as reintervention or above-ankle amputation, and primary patency. Secondary outcomes included perioperative blood transfusion requirements and the need for reoperation specifically for bleeding. We analyzed outcomes using Kaplan-Meier estimation and examined factors associated with choice of antithrombotic therapy via logistic regression. RESULTS: Our cohort included 2,760 patients (axillo-femoral bypass n=857, femoral-femoral bypass n=1,903) across 168 centers from 2009-2018. Mean age was 66.5 ±10.5 years and 59% were male. Patients were infrequently prescribed long-term anticoagulation (19%) or DAPT (22%). One-year primary patency was 86% and was similar by anticoagulation (log-rank p=0.12) and DAPT status (log-rank p=0.26). Freedom from MALE was 87% at 1 year and was slightly inferior for patients on anticoagulation (88% versus 83%, log-rank p=0.001) but was similar by DAPT (log-rank p=0.19). Transfusion was more common in patients who were anticoagulated compared to not (30% vs. 25%, p\u3c 0.01), but there was no increase in reoperation due to bleeding (anticoagulation 0.8 vs. 0.8, p=0.98). Anticoagulation was more commonly prescribed according to disease severity, such as rest pain (adjusted odds ratio (OR): 1.6 (95% confidence interval (CI): 1.20-2.20), tissue loss (OR: 1.9, CI: 1.28-2.73), or acute limb ischemia (OR: 1.9, CI: 1.35-2.71) or prior bypass graft (OR: 2.6, CI: 2.07-3.35). Patients were more commonly prescribed DAPT according to comorbidities, including hypertension (OR: 1.4, CI: 1.04-1.94) and coronary artery disease (OR: 1.6, CI 1.26-1.95). CONCLUSION: Antithrombotics are selectively employed in patients with extra-anatomic bypass to the lower extremity, the selection of which appears associated with disease severity for anticoagulants and patient comorbidities for DAPT. Primary patency and MALE rates are similar with focused utilization of anticoagulants or DAPT. Blood transfusions are more common among patients on antithrombotics without a difference in the need for reoperation for bleeding

A meta-analysis of anticoagulation for calf deep venous thrombosis

ObjectiveThis meta-analysis was initiated to assess the efficacy and safety of anticoagulation therapy for adult patients with isolated calf vein deep venous thrombosis (DVT).MethodsWe searched MEDLINE (1950-October 2010), the Cochrane Library (1993-October 2010), trial registries, meeting abstracts, and selected references, using no limits. Included studies compared the results of anticoagulation (vitamin K antagonist or therapeutic heparin) for a minimum of 30 days vs the results of no anticoagulation in adults with calf vein DVT proved by ultrasound imaging or venograph who were monitored for at least 30 days. Two independent reviewers extracted data using a piloted standardized form. Methodologic quality was assessed using the Cochrane Risk of Bias tool for randomized controlled trials (RCTs) and the Newcastle-Ottawa Quality Assessment Scale for cohort and case-control studies. Discrepancies were resolved by consensus or by a third reviewer. Authors were contacted for additional information if necessary. Outcomes were pooled using Peto fixed-effects models.ResultsOf 2328 studies identified, two RCTs and six cohorts (126 patients treated with anticoagulation and 328 controls) met selection criteria. The methodologic quality of most studies was poor. Pulmonary embolism (PE; odds ratio, 0.12; 95% confidence interval, 0.02-0.77; P = .03) and thrombus propagation (odds ratio, 0.29; 95% confidence interval, 0.14-0.62; P = .04) were significantly less frequent in those who received anticoagulation. Significant heterogeneity existed in studies reporting mortality rates, but these demonstrated a trend toward fewer deaths with anticoagulation. When limited to randomized trials, the protective effect of anticoagulation for PE was no longer statistically significant, but the benefit for preventing thrombus progression persisted. Adverse events such as bleeding were sparsely reported but favored controls (P = .65).ConclusionsOur review suggests that anticoagulation therapy for calf vein DVT may decrease the incidence of PE and thrombus propagation. However, due to poor methodologic quality and few events among included studies for PE, this finding is not robust. Thrombus propagation appears reduced with anticoagulation treatment. A rigorous RCT will assist in treatment decisions for calf vein DVT

A national survey of disease-specific knowledge in patients with an abdominal aortic aneurysm

OBJECTIVE: Patient education is a fundamental responsibility of medical providers caring for patients with abdominal aortic aneurysms (AAA). We sought to evaluate and quantify AAA-specific knowledge in patients under AAA surveillance and in patients who have undergone AAA repair. METHODS: In 2013, 1373 patients from 6 U.S. institutions were mailed an AAA-specific quality of life and knowledge survey. Of these patients, 1008 (73%) returned completed surveys for analysis. The knowledge domain of the survey consisted of nine questions. An AAA knowledge score was calculated for each patient based on the proportion of questions answered correctly. The score was then compared according to sex, race, and education level. Surveillance and repaired patients were also compared. RESULTS: Among 1008 survey respondents, 351 were under AAA surveillance and 657 had AAA repair (endovascular repair, 414; open, 179; unknown, 64). The majority of patients (85%) reported that their doctor\u27s office was their most important source of AAA information. The Internet and other written materials were each reported as the most important source of information 5% of the time with other patients reported 2% of the time. The mean AAA knowledge score was 47% (range 0%-100%; standard deviation, 23%) with a broad variation in percentage correct between questions. Thirty-two percent of respondents did not know that larger AAA size increases rupture risk, and 64% did not know that AAA runs in families. Only 15% of patients answered six or more of the nine questions correctly, and 23% of patients answered two or fewer questions correctly. AAA knowledge was significantly greater in men compared with women, whites compared with nonwhites, high school graduates compared with nongraduates, and surveillance compared with repaired patients. CONCLUSIONS: In a national survey of AAA-specific knowledge, patients demonstrated poor understanding of their condition. This may contribute to anxiety and uninformed decision making. The need for increased focus on education by vascular providers is a substantial unmet need