Postoperative Antithrombotic Regimen After Femoral Endarterectomy and Femoral-to-Above Knee Popliteal Bypass with PTFE
Start low-dose rivaroxaban 2.5 mg twice daily combined with aspirin 81-100 mg daily immediately postoperatively to reduce both major adverse cardiovascular events (MACE) and major adverse limb events (MALE), including graft thrombosis. 1
Primary Recommendation: Dual Pathway Inhibition
The 2024 ACC/AHA guidelines provide a Class I recommendation (strongest level of evidence) for the combination of low-dose rivaroxaban 2.5 mg twice daily plus low-dose aspirin after surgical revascularization for PAD. 1 This represents the first antithrombotic regimen proven to reduce total mortality and cardiovascular mortality in PAD patients following revascularization. 2
Why This Regimen for PTFE Grafts
PTFE grafts have higher thrombosis rates than venous grafts (20% vs 15% failure rate for above-knee femoropopliteal grafts), making aggressive antithrombotic therapy particularly important. 3
The VOYAGER PAD trial demonstrated that rivaroxaban 2.5 mg twice daily plus aspirin reduced MALE primarily by preventing acute limb ischemia, which is the most relevant outcome for your patient with a prosthetic graft and non-healing wounds. 1
Patients with CLTI (indicated by non-healing wounds) derive the greatest benefit from dual pathway inhibition, as they are at highest risk for both MACE and MALE. 1, 2
Bleeding Risk Considerations
This regimen increases ISTH major bleeding but not TIMI major bleeding. 1
Contraindications to dual pathway inhibition include: history of hemorrhagic or lacunar stroke, severe kidney disease, or need for full-intensity anticoagulation for another indication. 2
If your patient has high bleeding risk, proceed to the alternative regimen below.
Alternative Regimen: Dual Antiplatelet Therapy
If rivaroxaban is contraindicated, unavailable, or the patient has high bleeding risk:
Use dual antiplatelet therapy with clopidogrel 75 mg daily plus aspirin 81-100 mg daily for at least 1 month after surgical revascularization with a prosthetic graft. 1
Evidence for DAPT in Prosthetic Grafts
The 2024 ACC/AHA guidelines give DAPT after surgical revascularization with prosthetic grafts a Class IIb recommendation (may be reasonable) for at least 1 month. 1
The CASPAR trial showed that in the subgroup with prosthetic grafts, clopidogrel plus aspirin reduced graft occlusion, revascularization, amputation, or death without increasing major bleeding. 1
For venous grafts, DAPT showed no benefit, but your patient has a PTFE graft where the evidence is more favorable. 1
Duration of DAPT
Continue DAPT for 1 to 6 months after the procedure, then transition to single antiplatelet therapy. 1
The 2024 ESC guidelines support DAPT for 1-3 months post-revascularization, noting it improves patency without increasing bleeding in prosthetic grafts. 1
Long-Term Maintenance Therapy (After Initial Period)
After the initial 1-6 months of dual therapy:
Transition to single antiplatelet therapy with clopidogrel 75 mg daily indefinitely. 1, 4
Clopidogrel is preferred over aspirin for symptomatic PAD, reducing MI, stroke, or vascular death by 23.8% more than aspirin. 1, 4
Alternatively, aspirin 75-325 mg daily is acceptable if clopidogrel is not tolerated. 1
Critical Pitfalls to Avoid
Do NOT Use Full-Dose Anticoagulation
Avoid warfarin or therapeutic-dose DOACs unless there is another indication (e.g., atrial fibrillation). 2, 4
Full-intensity anticoagulation increases bleeding risk without reducing MACE or MALE in PAD patients. 2
The BOA trial showed vitamin K antagonists with INR 3-4.5 increased major bleeding 1.9-fold and fatal bleeding 1.3-fold, with only marginal benefit in high-risk prosthetic grafts. 1
Do NOT Continue Long-Term DAPT Beyond 6 Months
- Long-term DAPT (aspirin plus clopidogrel) beyond 6 months is not recommended for chronic PAD without recent revascularization due to increased bleeding risk without proven benefit. 2, 5
Do NOT Discontinue Antiplatelet Therapy Prematurely
- Thrombosis of PTFE grafts after discontinuation of antiplatelet therapy is a well-documented cause of acute limb ischemia requiring emergent intervention. 6
Additional Essential Medical Therapies
Beyond antithrombotic therapy, your patient with non-healing wounds requires:
High-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) to reduce cardiovascular events and mortality. 4
Aggressive smoking cessation with pharmacotherapy (varenicline, bupropion, or nicotine replacement) and referral to cessation programs. 4
Glycemic control targeting HbA1c <7% if diabetic, as this is particularly beneficial in CLTI for wound healing. 4
Multispecialty wound care including podiatry and wound specialists for advanced wound management and infection control. 4
Monitoring Strategy
Assess for bleeding complications particularly in the first 3 months of dual pathway therapy. 2
Monitor graft patency and limb symptoms at least annually with clinical assessment and ankle-brachial index. 2, 5
Reassess ischemic and bleeding risk at every follow-up visit to determine if therapy modification is needed. 2