Anticoagulation After Popliteal Artery Stenting
After popliteal artery stenting, patients should receive low-dose rivaroxaban 2.5 mg twice daily combined with low-dose aspirin (81-100 mg daily), not traditional anticoagulation. This dual pathway inhibition strategy is the strongest evidence-based approach for reducing both major adverse cardiovascular events (MACE) and major adverse limb events (MALE) following lower extremity revascularization 1.
Primary Recommendation: Dual Pathway Inhibition
The 2024 ACC/AHA guidelines provide a Class I recommendation (strongest level) for low-dose rivaroxaban 2.5 mg twice daily plus low-dose aspirin after endovascular or surgical revascularization for PAD 1. This combination represents the first antithrombotic regimen proven to reduce total mortality and cardiovascular mortality in PAD patients, making it superior to other antiplatelet strategies 2.
The European Society of Cardiology similarly recommends this combination (Class IIa) for patients following lower-limb revascularization who are not at high bleeding risk 1, 3.
Alternative: Dual Antiplatelet Therapy
If rivaroxaban is contraindicated or unavailable, dual antiplatelet therapy (DAPT) with clopidogrel 75 mg plus aspirin 81-100 mg daily is reasonable for at least 1-6 months after endovascular revascularization 1, 4. The European guidelines specifically recommend DAPT for at least one month after infrainguinal stent implantation 1.
However, DAPT is inferior to the rivaroxaban-aspirin combination for preventing limb-related events and does not reduce mortality 2.
What NOT to Do: Critical Pitfalls
Full-dose anticoagulation (warfarin or therapeutic-dose DOACs) should NOT be used solely for PAD or stenting 1, 3. Traditional anticoagulation increases bleeding risk without reducing MACE or MALE in PAD patients unless there is another indication such as atrial fibrillation 1, 4.
Long-term DAPT beyond 6 months is not recommended for chronic PAD without recent revascularization due to increased bleeding risk without proven benefit 1, 3, 2.
Risk Stratification for Treatment Selection
High ischemic risk features that favor rivaroxaban-aspirin combination include 3:
- Previous amputation
- Chronic limb-threatening ischemia
- Previous revascularization
- Diabetes mellitus
- Vascular disease in multiple beds
- Moderate kidney dysfunction (eGFR <60 mL/min/1.73 m²)
High bleeding risk contraindications to dual pathway therapy include 3:
- History of hemorrhagic or lacunar stroke
- Severe kidney disease
- Need for therapeutic anticoagulation for another indication
Special Circumstances
If the patient requires full-intensity anticoagulation for another indication (e.g., atrial fibrillation with CHA₂DS₂-VASc ≥2), adding single antiplatelet therapy is reasonable if bleeding risk is not high 1, 4. Triple therapy (anticoagulation plus DAPT) should be avoided due to excessive bleeding risk 3.
Monitoring Requirements
Patients should be monitored for bleeding complications, particularly in the first 3 months of dual pathway therapy 3. Clinical and functional status, medication adherence, and limb symptoms should be assessed at least annually, with reassessment of ischemic and bleeding risk at every follow-up 1, 3.