This chapter about antithrombotic
therapy for
peripheral arterial occlusive disease is part of the seventh ACCP Conference on Antithrombotic and
Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs, and Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004;126:179S-187S). Among the key recommendations in this chapter are the following: For patients with chronic limb
ischemia, we recommend lifelong
aspirin therapy in comparison to no antiplatelet
therapy in patients with clinically manifest coronary or
cerebrovascular disease (Grade 1A) and in those without clinically manifest coronary or
cerebrovascular disease (Grade 1C+). We recommend
clopidogrel over no antiplatelet
therapy (Grade 1C+) but suggest that
aspirin be used instead of
clopidogrel (Grade 2A). For patients with disabling
intermittent claudication who do not respond to conservative measures and who are not candidates for surgical or
catheter-based intervention, we suggest
cilostazol (Grade 2A). We suggest that clinicians not use
cilostazol in patients with less-disabling claudication (Grade 2A). In these patients, we recommend against the use of
pentoxifylline (Grade 1B). We suggest clinicians not use
prostaglandins (Grade 2B). In patients with
intermittent claudication, we recommend against the use of
anticoagulants (Grade 1A). In patients with acute arterial emboli or
thrombosis, we recommend treatment with immediate systemic anticoagulation with
unfractionated heparin (UFH) [Grade 1C]. We also recommend systemic anticoagulation with UFH followed by long-term
vitamin K antagonist (VKA) in patients with
embolism [Grade 1C]). For patients undergoing major vascular reconstructive procedures, we recommend UFH at the time of application of vascular cross-clamps (Grade 1A). In patients undergoing prosthetic infrainguinal bypass, we recommend
aspirin (Grade 1A). In patients undergoing infrainguinal femoropopliteal or distal vein bypass, we suggest that clinicians do not routinely use a VKA (Grade 2A). For routine patients undergoing infrainguinal bypass without special risk factors for occlusion, we recommend against VKA plus
aspirin (Grade 1A). For those at high risk of bypass occlusion and limb loss, we suggest VKA plus
aspirin (Grade 2B). In patients undergoing
carotid endarterectomy, we recommend
aspirin preoperatively and continued indefinitely (Grade 1A). In nonoperative patients with asymptomatic or recurrent
carotid stenosis, we recommend lifelong
aspirin (Grade 1C+). For all patients undergoing extremity balloon angioplasty, we recommend long-term
aspirin (Grade 1C+).