What medication should be started for a patient with impaired renal function and hyperlipidemia undergoing percutaneous transluminal angioplasty (PTA) and stent graft placement in the right common iliac artery after a right lower extremity angiogram?

Antiplatelet Therapy Following Iliac Artery Stent Placement

Start single antiplatelet therapy with either aspirin 75-325 mg daily OR clopidogrel 75 mg daily immediately after the procedure and continue indefinitely. 1, 2

Mandatory Long-Term Antiplatelet Therapy

• Single antiplatelet therapy is the standard of care for all patients undergoing peripheral artery PTA with or without stenting, with aspirin 75-100 mg daily or clopidogrel 75 mg daily recommended as equivalent first-line options 1

• The American College of Chest Physicians specifically recommends long-term aspirin (75-100 mg/day) or clopidogrel (75 mg/day) for patients undergoing peripheral artery PTA with or without stenting (Grade 1A recommendation) 1

• This antiplatelet therapy should be continued indefinitely to reduce major adverse cardiovascular events and cardiovascular mortality, which is the primary driver of morbidity and mortality in peripheral arterial disease patients 1, 2

Dual Antiplatelet Therapy Considerations

• Dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel may be reasonable to reduce limb-related events following revascularization, though the evidence is less established for intermittent claudication compared to coronary interventions 1

• After venous stent placement (different context but relevant), the use of antiplatelet therapy with concomitant anticoagulation in patients perceived to be at high risk of rethrombosis may be considered (Class IIb recommendation) 1

• The American College of Radiology notes that DAPT may be reasonable to reduce limb-related events in patients following revascularization, though this is not as strongly supported as single antiplatelet therapy 1

Essential Adjunctive Medical Management

Beyond antiplatelet therapy, initiate the following medications given the patient's comorbidities:

High-Dose Statin Therapy

• Start high-dose statin therapy immediately if tolerated (Class IA recommendation), as this is indicated for all patients with peripheral arterial disease regardless of lipid profile results 1, 2, 3

• Statins reduce cardiovascular events and improve outcomes in all PAD patients 3

Renal Function Considerations

• Given impaired renal function, dose-adjust medications appropriately and avoid nephrotoxic agents 1

• Monitor renal function closely, as chronic renal insufficiency is an independent predictor of iliac intervention failure 2

Blood Pressure Management

• Administer antihypertensive therapy to reduce the risk of major adverse cardiovascular events including stroke, myocardial infarction, heart failure, or cardiovascular death 1, 3

Critical Medication Selection Algorithm

For this specific patient with impaired renal function and hyperlipidemia:

1. Start clopidogrel 75 mg daily (preferred over aspirin given renal impairment, as clopidogrel may have better cardiovascular outcomes in PAD patients based on the CAPRIE trial subgroup analysis showing hazard ratio 0.78 for cardiovascular mortality and MACE) 1, 4

2. Start high-dose atorvastatin 40-80 mg daily (dose-adjust based on renal function and tolerability) 1, 2

3. Optimize blood pressure control with appropriate antihypertensive agents 1, 3

4. Consider adding cilostazol 100 mg twice daily if claudication symptoms persist, as this improves walking distance in intermittent claudication patients 1, 3

Duration of Therapy

• Single antiplatelet therapy should be continued indefinitely 1, 2

• If DAPT is initiated, the optimal duration is not well-established for peripheral interventions, though coronary stent data suggests at least 1 month for bare metal stents and 3-6 months for drug-eluting stents 1

• Dutch practice patterns show high variability in DAPT duration after femoral interventions, reflecting the lack of strong evidence 5

Common Pitfalls to Avoid

• Do not use anticoagulation alone without antiplatelet therapy, as this is not supported for peripheral arterial stenting 1

• Do not discontinue antiplatelet therapy prematurely, as early discontinuation is a major predictor of stent thrombosis and adverse cardiovascular events 6

• Do not forget to address concomitant superficial femoral artery stenosis >50% if present, as this is a critical predictor of iliac intervention failure with only 36% 3-year primary patency if left untreated 2, 3

• Avoid combining warfarin with dual antiplatelet therapy unless absolutely necessary (e.g., mechanical heart valve, atrial fibrillation with high stroke risk), as this significantly increases bleeding risk 1