Antiplatelet Therapy After Bilateral Lower Extremity Stenting
Yes, patients with bilateral lower extremity stents need antiplatelet therapy, but the optimal regimen is low-dose rivaroxaban 2.5 mg twice daily plus aspirin 81-100 mg daily, NOT dual antiplatelet therapy with Plavix (clopidogrel) plus aspirin for long-term management. 1, 2
Immediate Post-Revascularization Period (First 1-6 Months)
For the first 1-6 months after lower extremity stent placement, dual pathway inhibition with rivaroxaban 2.5 mg twice daily plus aspirin 81-100 mg daily is the Class I (strongest) recommendation to reduce major adverse cardiovascular events (MACE) and major adverse limb events (MALE), and represents the first antithrombotic regimen proven to reduce total mortality and cardiovascular mortality in peripheral artery disease (PAD) patients. 2
- 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. 3, 2
- After infrainguinal stent implantation specifically, DAPT should continue for at least one month at minimum. 2
Long-Term Management (Beyond 6 Months)
Long-term dual antiplatelet therapy with aspirin plus clopidogrel is NOT recommended for chronic PAD without recent revascularization (within 6 months) due to increased bleeding risk without proven benefit. 1, 2
- The European Society of Cardiology explicitly states that long-term dual antiplatelet therapy is not indicated in patients with PAD. 1
- After the initial 1-6 month post-revascularization period, patients should be transitioned to either:
- Single antiplatelet therapy (aspirin 75-100 mg daily OR clopidogrel 75 mg daily) for standard-risk patients 1, 2
- Continued dual pathway inhibition (rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily) for high-risk patients with features such as previous amputation, chronic limb-threatening ischemia, previous revascularization, heart failure, diabetes, vascular disease in multiple beds, or moderate kidney dysfunction (eGFR <60 mL/min/1.73 m²) 2
Critical Pitfalls to Avoid
Do NOT use full-dose anticoagulation (warfarin or therapeutic-dose DOACs) solely for PAD or stenting, as it increases bleeding risk without reducing MACE or MALE unless there is another indication such as atrial fibrillation. 2
Do NOT continue dual antiplatelet therapy (aspirin + clopidogrel) indefinitely beyond 6 months in chronic PAD patients without recent revascularization, as this significantly increases bleeding risk without proven cardiovascular or limb benefit. 1, 2
Do NOT assume coronary stent guidelines apply to peripheral stents - the evidence cited in coronary stent guidelines 3 addresses coronary artery disease, not peripheral arterial disease, and the duration and intensity of antiplatelet therapy differs substantially between these two vascular beds.
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. 2
- Patients who are asymptomatic from a vascular standpoint (no claudication symptoms) or have increased bleeding vulnerability should be considered for de-escalation from dual antiplatelet therapy to single agent therapy. 1
Monitoring Requirements
- Assess for bleeding complications, particularly in the first 3 months of dual pathway therapy. 2
- Evaluate clinical and functional status, medication adherence, and limb symptoms at least annually. 1, 2
- Reassess ischemic and bleeding risk at every follow-up visit. 2
- If claudication recurs or new vascular symptoms develop, reassess with ankle-brachial index and consider vascular imaging. 1