Antithrombotic Therapy in Peripheral Arterial Occlusive Disease G. ltztrick Clagett, M.D., Chairman Roberl A Graor, M. D. Edwin W Salzman, M.D.

is the cause of the vast majority of cases of chronic peripheral arterial occlusive disease. The arteries most frequently involved, in order of occurrence, include femoro-popliteal-tibial, aorto-iliac, carotid and vertebral, splanchnic and renal, and brachiocephalic. Fibromuscular dysplasia, inflammatory arteridites, and congenital arterial malformation are much rarer etiologies of arterial insufficiency. The causes of acute arterial occlusions are embolism, thrombosis, and trauma. The goal of therapy in chronic occlusive disease is to prevent or eliminate ischemic symptoms or progression to vascular occlusion. The objectives of therapy in acute arterial occlusion are to preserve life and limb and to restore blood flow. Antithrombotic therapy is rational to consider in the treatment of patients with peripheral vascular disease; in chronic disease, to prevent progression and thrombotic occlusion or to prevent thrombotic complications after vascular reconstructions and other interventions; in acute arterial occlusion from emboli or thrombosis, to prevent propagation of thrombi into proximal and distal branches or reocclusion after surgical or interventional procedures reestablish flow; or in the case of embolism, to prevent recurrence. The antithrombotic agents available are anticoagulants, platelet-active agents, thrombolytic agents, and dextran (Table 1). ~herosclerosis

CHRONIC EXTREMITY ARTERIAL INSUFFICIENCY

Epidemiologic studies have documented that 2 to 3 percent of men and 1 to 2 percent of women 60 years of age or older have intermittent claudication. 1•2 The prevalence, however, is threefold to fourfold higher when sensitive noninvasive tests are applied to the limbs of asymptomatic as well as symptomatic individuals. 3 The natural course of chronic lower extremity arterial insufficiency is that after five to ten years, approximately 70 to 80 percent of patients remain unchanged or improve, 20 to 30 percent have progression and require intervention, and less than 10 percent require amputation. 4 •5 Despite this rather benign prognosis for the limb, intermittent claudication may be viewed as an ominous sign of underlying disseminated atherosclerosis, and affiicted individuals have a twofold to threefold increase in cardiovascular mortality on 516$

long-term follow-up in comparison to age-matched control subjects. I.2 ·6 The prognosis for both limb and life is worse for more severely affected individuals. 5 ·6 It is rational to use antithrombotic therapy in patients with intermittent claudication to prevent stroke, myocardial infarction, and death. At present the best antiplatelet therapy appears to be aspirin, 325 mg or less daily. This recommendation is based on indirect evidence from a meta-analysis involving more than 29,000 patients with vascular disease from 31 trials. 7 Aspirin therapy reduced vascular mortality (death most commonly from myocardial infarction and stroke) by 15 percent (p

Antithrombotic therapy in peripheral arterial occlusive disease.

Antithrombotic Therapy in Peripheral Arterial Occlusive Disease G. ltztrick Clagett, M.D., Chairman Roberl A Graor, M. D. Edwin W Salzman, M.D. is th...
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