What is the recommended duration of Dual Antiplatelet Therapy (DAPT) after angiography and percutaneous transluminal angioplasty (PTA) of the lower extremities?

From the Guidelines

The recommended duration of Dual Antiplatelet Therapy (DAPT) after angiography and percutaneous transluminal angioplasty (PTA) of the lower extremities is 1 to 3 months, particularly if a stent is placed in a small peripheral vessel. This recommendation is based on the practice of many interventionists, who provide a loading dose of clopidogrel in addition to aspirin pre-procedure and then continue dual antiplatelet therapy for 1 to 3 months post-PTA 1. Although the evidence is low-quality and largely extrapolated from coronary artery stenting trials, the use of DAPT for 1 to 3 months is a common practice in patients undergoing PTA with stent placement for peripheral artery disease (PAD) 1.

The standard DAPT regimen consists of aspirin 81-100 mg daily combined with clopidogrel 75 mg daily. For patients undergoing plain balloon angioplasty or bare metal stent placement, 1 month of DAPT is often sufficient. However, for drug-coated balloons or drug-eluting stents, extending DAPT to 2-3 months is generally recommended due to the delayed healing process associated with these devices. After completing the DAPT course, patients should continue indefinite single antiplatelet therapy, typically with aspirin 81 mg daily.

Some key points to consider when determining the duration of DAPT include:

• The type of intervention performed (e.g. plain balloon angioplasty, bare metal stent placement, drug-coated balloon, or drug-eluting stent)
• The presence of complex lesions or multiple interventions
• The patient's individual risk factors, such as bleeding risk or cardiovascular risk
• The results of studies, such as the Cochrane review, which found a possible reduction in reocclusion at 6 months in patients taking aspirin plus dipyridamole compared with placebo 1

It is essential to weigh the benefits of DAPT against the risks of bleeding and to individualize treatment based on patient-specific factors. However, the general recommendation of 1 to 3 months of DAPT after PTA of the lower extremities remains the most appropriate course of action, based on current evidence and practice 1.

From the Research

Duration of Dual Antiplatelet Therapy (DAPT) after Angiography and Percutaneous Transluminal Angioplasty (PTA) of the Lower Extremities

• The recommended duration of DAPT after angiography and PTA of the lower extremities is not explicitly stated in the provided studies, but we can infer from the information related to coronary angioplasty and peripheral artery disease (PAD).
• For patients undergoing PTA/Stenting for PAD, most interventionists provide a loading dose of clopidogrel in addition to aspirin followed by dual antiplatelet therapy for a duration of 1 to 3 months after PTA 2.
• The duration of DAPT may vary depending on the patient's risk of bleeding and ischemia, with some studies suggesting 1-18 months of DAPT after percutaneous coronary intervention (PCI) 3.
• The American College of Cardiology/American Heart Association (ACC/AHA) recommends aspirin plus a P2Y12 inhibitor for at least 12 months for patients with acute coronary syndrome 4.
• However, the optimal duration of DAPT after PTA of the lower extremities is not well established, and more research is needed to determine the best course of treatment.

Considerations for DAPT Duration

• Patient characteristics, such as risk of bleeding and myocardinal ischemia, should be taken into account when determining the duration of DAPT 4.
• The type of stent used, such as bare-metal or drug-eluting, may also influence the duration of DAPT 5.
• The risk of complications, such as stent thrombosis and major bleeding, should be carefully considered when deciding on the duration of DAPT 5, 4.