背景:在接受外周动脉疾病(PAD)血运重建的患者中,与单用阿司匹林相比,低剂量因子Xa抑制剂(FXaI)与阿司匹林一起服用可改善肢体和心血管结局.此外,在心房颤动和静脉血栓栓塞中,对于慢性抗凝,建议使用FXaI优于维生素K拮抗剂(VKA)。虽然有研究评估了PAD患者的不同围手术期抗凝方案,对接受外周血管介入治疗(PVI)的PAD患者进行慢性抗凝治疗的最佳方案尚未确定.该分析比较了需要使用FXaI和VKA进行慢性抗凝治疗的PVI后患者的结局。
方法:使用血管质量倡议-PVI数据库。患者在手术前持续接受FXaI或VKA治疗,在放电时,长期随访的患者被定义为接受慢性抗凝治疗的患者.患者人口统计学,程序细节,比较FXaI组和VKA组的围手术期和长期结局.
结果:共分析了109,268例患者,和6,885用FXaI(N=2,427)或VKA(N=4,458)慢性抗凝。使用VKA抗凝的患者更常见为男性(65.3%vs.61.0%,P<0.001)与终末期肾病(9.7%vs.4.6%,P<0.001),并且更有可能治疗慢性威胁肢体缺血(58.1%vs.52.7%,P<0.001)。与FXaI相比,服用VKA的患者PVI后血肿发生率明显更高(3.5%vs.1.9%,P<0.001)。多因素logistic回归分析显示,VKA比FXaI增加围手术期血肿(比值比=1.89[1.30-2.82])。与服用VKA的患者相比,那些接受FXaI的人的大截肢率较低(6.7%vs.8.4%,P=0.020)和死亡率(7.6%vs.15.2%,P≤0.001)。使用Kaplan-Meier分析,持续接受FXaI抗凝治疗的患者在PVI后无截肢生存率得到改善.调整显著的患者和程序特征,Cox比例风险回归表明,与FXaI相比,使用VKA的患者发生严重截肢或死亡的风险增加(风险比1.61,[1.36-1.90])。
结论:在接受PVI的PAD患者中,与VKA相比,FXaI的慢性抗凝治疗与良好的围手术期和长期预后相关。与VKA相比,FXaI应该是PAD患者接受PVI的慢性抗凝药物。
BACKGROUND: In patients undergoing revascularization for peripheral arterial disease (PAD), low-dose Factor Xa inhibitors (FXaI) taken with aspirin improved limb and cardiovascular outcomes compared to aspirin alone. Furthermore, in atrial fibrillation and venous thromboembolism, FXaI are recommended over vitamin K antagonists (VKA) for chronic anticoagulation. While studies have evaluated different perioperative anticoagulation regimens in patients treated for PAD, the optimal regimen for chronic anticoagulation in patients with PAD undergoing peripheral vascular intervention (PVI) has not been determined. This analysis compares outcomes of patients after PVI that require chronic anticoagulation with FXaI and VKA.
METHODS: The Vascular Quality Initiative-PVI database was used. Patients consistently treated with FXaI or VKA before the procedure, at discharge, and on long-term follow-up were defined as those receiving chronic anticoagulation. Patient demographics, procedural details, and perioperative and long-term outcomes were compared between FXaI and VKA groups.
RESULTS: A total of 109,268 patients were analyzed, and 6,885 were chronically anticoagulated with FXaI (N = 2,427) or VKA (N = 4,458). Patients anticoagulated with VKA were more frequently males (65.3% vs. 61.0%, P < 0.001) with end-stage renal disease (9.7% vs. 4.6%, P < 0.001) and more likely to be treated for chronic limb-threatening ischemia (58.1% vs. 52.7%, P < 0.001). Rates of hematoma following PVI were significantly higher in patients taking VKA compared to FXaI (3.5% vs. 1.9%, P < 0.001). Multivariable logistic regression analysis showed that VKA were associated with increased perioperative hematoma than FXaI (odds ratio = 1.89 [1.30-2.82]). Compared to patients taking VKA, those receiving FXaI had lower rates of major amputation (6.7% vs. 8.4%, P = 0.020) and mortality (7.6% vs. 15.2%, P ≤ 0.001). Using Kaplan-Meier analysis, patients consistently anticoagulated with FXaI had improved amputation-free survival after PVI. Adjusting for significant patient and procedural characteristics, Cox proportional hazard regression demonstrated that there is an increased risk for major amputation or mortality in patients using VKA compared to FXaI (hazard ratio 1.61, [1.36-1.90]).
CONCLUSIONS: Chronic anticoagulation with FXaI as compared to VKA was associated with superior perioperative and long-term outcomes in patients with PAD undergoing PVI. FXaI should be the preferred agents over VKA for chronic anticoagulation in patients with PAD undergoing PVI.