Stronger Blood Clot Prevention Measures Needed After Leg Artery Procedures in High-Risk Patients

Chronic limb-threatening ischemia (CLTI), the most severe form of peripheral artery disease (PAD), significantly reduces blood flow to the legs and feet. Despite undergoing lower limb revascularization (LLR) procedures such as angioplasty, stenting, or bypass surgery to restore circulation, patients with CLTI remain at high risk for life-altering complications, including Major Adverse Limb Events (MALE) and Major Adverse Cardiovascular Events (MACE). Now, a new expert statement published in the European Heart Journal provides much-needed clinical guidance to help prevent blood clots in CLTI patients following LLR procedures.

This comprehensive review was developed by an international team of heart and vascular experts, including researchers from the University of Surrey (Guildford, UK). It represents the first focused clinical statement targeting this high-risk patient population and highlights the current lack of dedicated research on optimal post-procedure therapies for blood clot prevention in CLTI cases. The team analyzed 34 scientific studies to compile the statement. While only three large randomized controlled trials (RCTs) specifically assessed antithrombotic treatments in CLTI patients after LLR, none demonstrated clearly superior outcomes. However, promising evidence came from eight broader RCTs in general PAD populations—which included some CLTI patients—suggesting that dual antiplatelet therapy (DAPT) might be effective in preventing limb complications.

DAPT typically involves a combination of two antiplatelet drugs, most commonly aspirin and clopidogrel, which prevent platelets from clumping together to form clots. Additionally, data from 22 observational studies supported the use of DAPT, showing it was associated with reduced risk of MALE, increased survival rates, and lower chances of amputation. Importantly, the statement identifies Dual Pathway Inhibition (DPI)—a combination of aspirin and a low dose of the blood thinner rivaroxaban—as the only treatment validated by a large, high-quality RCT to significantly reduce the risks of MALE, MACE, and repeat procedures on the affected limb. This makes DPI a particularly promising strategy for improving both limb and cardiovascular outcomes in CLTI patients after revascularization. By offering structured, evidence-based guidance, the new statement aims to standardize treatment approaches, reduce complications, and ultimately improve long-term outcomes for CLTI patients undergoing limb-saving procedures.

“This review highlights a need for more dedicated, large-scale research specifically focused on blood clot prevention therapies for patients with CLTI after their revascularization procedures,” said University of Surrey Prof. Christian Heiss, an author of the review. “While current guidelines offer general advice for peripheral artery disease, the unique vulnerability of CLTI patients, including their susceptibility to bleeding complications, demands tailored approaches to improve their outcomes and prevent negative consequences. Additionally, a direct comparison of DPI versus DAPT in CLTI patients after LLR is needed to determine the best approach.”