Mono or Dual Antiplatelet Therapy for Treating Patients with Peripheral Artery Disease after Lower Extremity Revascularization: A Systematic Review and Meta-Analysis

• The efficacy of dual antiplatelet therapy (DAPT) for patients with peripheral artery disease (PAD) receiving various interventions such as surgical bypass and endovascular procedures irrespective of stent replacement remains controversial
• This study aimed to compare and analyse the prognosis for symptomatic PAD patients receiving DAPT vs. monotherapy following lower-limb revascularisation procedures
• This study provides evidence that DAPT should be prescribed to PAD patients after lower extremity revascularisation without worrying about major bleeding

Literatures were searched from PubMed/MEDLINE, Embase, and Cochrane databases (up to November 2021) to identify studies that report the efficacy, duration, and bleeding complications related to DAPT or monotherapy in PAD patients following revascularisation procedures. Further articles were identified by reviewing the references of the identified studies.

• All-cause mortality

• Major adverse cardiac and cerebrovascular events, including myocardial infarction, stroke (ischemic or haemorrhage), and major adverse limb events (MALEs), including major amputation (above the ankle), amputation free survival, and target lesion revascularisation

• Symptomatic PAD patients presented with intermittent claudication or critical limb Ischaemia who underwent surgical bypass or endovascular intervention
• History of monotherapy (aspirin or clopidogrel) or DAPT (defined as aspirin plus any P2Y12 receptor antagonist, including clopidogrel, ticagrelor, prasugrel, or ticlopidine) after intervention
• Post-intervention DAPT treatment longer than 1 month
• Median postoperative follow-up longer than 1 year

• Three randomised controlled trials (RCTs) and 7 non-RCTs (NRCTs), with a total 74,651 patients were included
• DAPT in post-intervention PAD patients was associated with lower rates of all-cause mortality (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.79–0.94; p < 0.01), MALEs (HR, 0.60; 95% CI, 0.47–0.78; p < 0.01), and major amputation (HR, 0.78; 95% CI, 0.64–0.96) after intervention.
• DAPT vs. monotherapy was not associated with major bleeding events (odds ratio [OR], 1.22; 95% CI, 0.69–2.18; p = 0.50) but was associated with higher rate of minor bleeding as a complication (OR = 2.54; 95% CI, 1.59–4.08; p < 0.01)

Among patients with PAD who underwent lower-extremity revascularisation, DAPT vs monotherapy reduced all-cause mortality, occurrence of MALEs, and amputation without increasing the risk of major bleeding.

• Compared with RCTs, NRCTs are limited by an unavoidable additional risk of bias and provide less precise information
• Pooled forest plot was used as part of the meta-analysis of RCTs and NRCTs; this may have concerns regarding the overall effect
• The research objects in the included studies are mostly related to western countries, hence the application of these results to other populations is questionable