Advertisement

Effect of Direct Oral Anticoagulants Versus Warfarin on Patency in High-Risk Bypass Patients

      Background

      The use of warfarin for anticoagulation in thromboembolic disease has been the mainstay of treatment. Direct oral anticoagulants (DOACs) have demonstrated equivalent anticoagulant effects, without increased bleeding risks or need for frequent monitoring. However, the role of DOACs remains unclear in the setting of replacing warfarin for high-risk peripheral artery disease (PAD) interventions. The purpose of this study is to evaluate the efficacy of DOACs compared to warfarin during the postoperative period in patients that underwent a lower extremity high-risk bypass (HRB).

      Methods

      The study is a single institution, retrospective review of all lower extremity HRBs between January 2012 and June 2021, who were previously placed on or started on anticoagulation with a DOAC or warfarin. The HRB group included all patients undergoing femoral to above or below knee bypass with an adjunct procedure, or below knee bypass with synthetic or composite vein conduit. All demographics, preoperative factors, and complications were evaluated with respect to DOAC versus warfarin.

      Results

      A total of 44 patients (28 males; average age 68.8 ± 10.9) underwent an HRB during the study period. There were no significant differences in demographics and preoperative characteristics between the 2 groups. Among patient comorbidities, coronary artery disease was found to be significantly higher in patients on DOACs (P = 0.03). The 12-month primary patency rate was 83.3% versus 57.1%, for DOAC versus warfarin respectively (P = 0.03). Multivariate analyses revealed that <30-day reinterventions contribute to 12-month patency (P = 0.02).

      Conclusions

      Patients who underwent lower extremity HRB with postoperative DOAC appeared to exhibit higher graft patency rates than those who were placed on warfarin. Due to their low incidence of undesirable side effects and the lack of frequent monitoring, DOACs could be considered a safe alternative to warfarin in the postoperative period for patients with HRB.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Annals of Vascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Lancaster R.T.
        • Conrad M.F.
        • Patel V.I.
        • et al.
        Predictors of early graft failure after infrainguinal bypass surgery: a risk-adjusted analysis from the NSQIP.
        Eur J Vasc Endovasc Surg. 2012; 43: 549-555
        • Jackson M.R.
        • Belott T.P.
        • Dickason T.
        • et al.
        The consequences of a failed femoropopliteal bypass: comparison of saphenous vein and PTFE grafts.
        J Vasc Surg. 2000; 32: 498-505
        • Normahani P.
        • Anwar I.Y.
        • Courtney A.
        • et al.
        Factors associated with infrainguinal bypass graft patency at 1-year; a retrospective analysis of a single centre experience.
        Perfusion. 2022; 37: 276-283
        • Tangelder M.J.D.
        • Lawson J.A.
        • Algra A.
        • et al.
        Systematic review of randomized controlled trials of aspirin and oral anticoagulants in the prevention of graft occlusion and ischemic events after infrainguinal bypass surgery.
        J Vasc Surg. 1999; 30: 701-709
        • Monaco M.
        • Tommaso L.D.
        • Pinna G.B.
        • et al.
        Combination therapy with warfarin plus clopidogrel improves outcomes in femoropopliteal bypass surgery patients.
        J Vasc Surg. 2012; 56: 96-105
        • Jackson M.R.
        • Johnson W.C.
        • Williford W.O.
        • et al.
        The effect of anticoagulation therapy and graft selection on the ischemic consequences of femoropopliteal bypass graft occlusion: results from a multicenter randomized clinical trial.
        J Vasc Surg. 2002; 35: 292-298
        • Sarac T.P.
        • Huber T.S.
        • Back M.R.
        • et al.
        Warfarin improves the outcome of infrainguinal vein bypass grafting at high risk for failure.
        J Vasc Surg. 1998; 28: 446-457
        • Liang N.L.
        • Baril D.T.
        • Avgerinos E.D.
        • et al.
        Comparative effectiveness of anticoagulation on mid-term infrainguinal bypass graft patency.
        J Vasc Surg. 2017; 66: 499-505.e2
        • Tangelder M.J.D.
        • Algra A.
        • Lawson J.A.
        • et al.
        Optimal oral anticoagulant intensity to prevent secondary ischemic and hemorrhagic events in patients after infrainguinal bypass graft surgery.
        J Vasc Surg. 2001; 33: 522-527
        • Brumberg R.S.
        • Back M.R.
        • Armstrong P.A.
        • et al.
        The relative importance of graft surveillance and warfarin therapy in infrainguinal prosthetic bypass failure.
        J Vasc Surg. 2007; 46: 1160-1166
        • Obi A.T.
        • Thompson J.R.
        • Beaulieu R.J.
        • et al.
        Bleeding and thrombotic outcomes associated with postoperative use of direct oral anticoagulants after open peripheral artery bypass procedures.
        J Vasc Surg. 2020; 72: 1996-2005.e4
        • Conte M.S.
        • Pomposelli F.B.
        • Clair D.G.
        • et al.
        Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication.
        J Vasc Surg. 2015; 61: 2S-41S
        • Kumbhani D.J.
        • Cannon C.P.
        • Beavers C.J.
        • et al.
        2020 ACC expert Consensus decision pathway for anticoagulant and antiplatelet therapy in patients with atrial fibrillation or venous thromboembolism undergoing percutaneous coronary intervention or with atherosclerotic cardiovascular disease: a report of the American college of cardiology solution set oversight committee.
        J Am Coll Cardiol. 2021; 77: 629-658
        • Chen A.
        • Stecker E.
        • Warden B.A.
        Direct oral anticoagulant use: a practical guide to common clinical challenges.
        J Am Heart Assoc. 2020; 9: e017559
        • Eikelboom J.W.
        • Connolly S.J.
        • Bosch J.
        • et al.
        Rivaroxaban with or without aspirin in stable cardiovascular disease.
        N Engl J Med. 2017; 377: 1319-1330
        • Bonaca M.P.
        • Bauersachs R.M.
        • Anand S.S.
        • et al.
        Rivaroxaban in peripheral artery disease after revascularization.
        N Engl J Med. 2020; 382: 1994-2004
        • Turgeon R.D.
        • Ackman M.L.
        • Babadagli H.E.
        • et al.
        The role of direct oral anticoagulants in patients with coronary artery disease.
        J Cardiovasc Pharmacol Ther. 2019; 24: 103-112
        • Gallu M.
        • Marrone G.
        • Legramante J.M.
        • et al.
        Female sex as a thromboembolic risk factor in the era of nonvitamin K antagonist oral anticoagulants.
        Cardiovasc Ther. 2020; 2020: 1743927
        • Raccah B.H.
        • Perlman A.
        • Zwas D.R.
        • et al.
        Gender differences in efficacy and safety of direct oral anticoagulants in atrial fibrillation: systematic review and network meta-analysis.
        Ann Pharmacother. 2018; 52: 1135-1142