What is the recommended anti-coagulation therapy for a patient after femoral artery stent insertion?

Anticoagulation After Femoral Artery Stent Insertion

After femoral artery stent insertion, dual antiplatelet therapy (DAPT) with aspirin 75-100 mg daily plus clopidogrel 75 mg daily is the standard treatment, NOT anticoagulation. 1

Immediate Post-Procedure Management

Antiplatelet Therapy (Not Anticoagulation)

• Loading doses should be administered before or at the time of stenting: clopidogrel 600 mg loading dose if not already on maintenance therapy 1
• Aspirin 75-100 mg daily should be started immediately and continued indefinitely 1
• Clopidogrel 75 mg daily should be continued for at least 6 months after stenting 1

Periprocedural Anticoagulation (During Procedure Only)

• Unfractionated heparin during the procedure to maintain ACT 300-350 seconds (initial bolus 100 units/kg, with supplemental dosing as needed) 1
• Anticoagulation should be discontinued after the procedure unless there is a compelling indication to continue 1
• Routine postprocedural intravenous heparin is NOT recommended due to increased bleeding risk without proven benefit 1

Duration of Dual Antiplatelet Therapy

Standard Duration

• For patients without high bleeding risk: DAPT for 6 months minimum 1
• After 6 months, transition to single antiplatelet therapy (aspirin or clopidogrel) indefinitely 1

Modified Duration Based on Bleeding Risk

• For patients at very high bleeding risk: DAPT may be shortened to 1 month 1
• For patients at high bleeding risk but not high ischemic risk: DAPT for 1-3 months, then single antiplatelet therapy 1

Special Circumstances

If Oral Anticoagulation is Required (e.g., Atrial Fibrillation)

• Triple therapy (aspirin + clopidogrel + anticoagulant) should be limited to ≤1 week post-procedure 1
• After 1 week, discontinue aspirin and continue dual therapy with clopidogrel 75 mg daily plus oral anticoagulant for up to 6 months 1
• After 6 months, continue oral anticoagulant alone 1
• Direct oral anticoagulants (DOACs) are preferred over warfarin when eligible 1

Complications Requiring Extended Anticoagulation

• If angiographic dissection, mural thrombus, or new neurological symptoms occur: consider heparin for 24 hours (APTT 1.5-2.3 times control) 1
• Alternative: enoxaparin 1 mg/kg subcutaneously twice daily 1

Bleeding Risk Mitigation

• Proton pump inhibitor should be added for gastrointestinal protection during DAPT 1, 2
• Avoid omeprazole and esomeprazole as they inhibit CYP2C19 and reduce clopidogrel effectiveness 2
• Use alternative PPIs such as pantoprazole or lansoprazole 2

Critical Pitfalls to Avoid

• Do NOT use fondaparinux as the sole anticoagulant during the procedure due to increased catheter thrombosis risk 1
• Do NOT continue systemic anticoagulation routinely after the procedure unless specific high-risk features are present 1
• Do NOT use warfarin or other anticoagulants as primary therapy - this is outdated practice associated with worse outcomes compared to DAPT 3
• Never prematurely discontinue DAPT as this is the strongest predictor of stent thrombosis 4

Key Distinction: Peripheral vs Coronary Stenting

While the evidence base is stronger for coronary stenting 1, the principles apply to femoral artery stenting with the understanding that:

• Antiplatelet therapy (not anticoagulation) is the cornerstone of post-stent management 1, 3
• Historical use of warfarin after peripheral stenting has been abandoned in favor of DAPT 3
• Acceptable patency rates (75% at 18 months) are achieved with DAPT alone without long-term anticoagulation 3