Antithrombotic agents for preventing thrombosis after infrainguinal arterial bypass surgery - PubMed (original) (raw)

Review

Antithrombotic agents for preventing thrombosis after infrainguinal arterial bypass surgery

Alistair J Geraghty et al. Cochrane Database Syst Rev. 2011.

Abstract

Background: Peripheral arterial disease (PAD) is frequently treated by either an infrainguinal autologous (using the patient's own veins) or synthetic graft bypass. The rate of occlusion of the graft after one year is between 12% and 60%. To prevent occlusion, patients are treated with an antiplatelet or antithrombotic drug, or a combination of both. Little is known about which drug is optimal to prevent infrainguinal graft occlusion. This is an update of a Cochrane review first published in 2003.

Objectives: To evaluate whether antithrombotic treatment improves graft patency, limb salvage and survival in patients with chronic PAD undergoing infrainguinal bypass surgery.

Search strategy: The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (last searched August 2010) and the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 3).

Selection criteria: Randomised, controlled trials; two review authors independently assessed the methodological quality of each trial using a standardised checklist.

Data collection and analysis: Data collected included patient details, inclusion and exclusion criteria, type of graft, antithrombotic therapy, outcomes, and side effects.

Main results: A total of 14 trials were included in this review; 4970 patient results were analysed. Four trials evaluating vitamin K antagonists (VKA) versus no VKA suggested that oral anticoagulation may favour autologous venous, but not artificial, graft patency as well as limb salvage and survival. Two other studies comparing VKA with aspirin (ASA) or aspirin and dipyridamole provided evidence to support a positive effect of VKA on the patency of venous but not artificial grafts. Three trials comparing low molecular weight heparin (LMWH) to unfractionated heparin (UFH) failed to demonstrate a significant difference on patency. One trial comparing LMWH with placebo found no significant improvement in graft patency over the first postoperative year in a population receiving aspirin. One trial showed an advantage for LMWH versus aspirin and dipyridamol at one year for patients undergoing limb salvage procedures. Perioperative administration of ancrod showed no greater benefit when compared to unfractionated heparin. Dextran 70 showed similar graft patency rates to LMWH but a significantly higher proportion of patients developed heart failure with dextran.

Authors' conclusions: Patients undergoing infrainguinal venous graft are more likely to benefit from treatment with VKA than platelet inhibitors. Patients receiving an artificial graft benefit from platelet inhibitors (aspirin). However, the evidence is not conclusive. Randomised controlled trials with larger patient numbers are needed in the future to compare antithrombotic therapies with either placebo or antiplatelet therapies.

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Conflict of interest statement

None known

Figures

1

1

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

2

2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

3

3

CAPPA feedback April 2014: Patency at day 30

4

4

CAPPA feedback April 2014: Mortality at day 30

1.1

1.1. Analysis

Comparison 1: Occlusion in all bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 1: Occlusion in all bypasses, 3 months

1.2

1.2. Analysis

Comparison 1: Occlusion in all bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 2: Occlusion in all bypasses, 6 months

1.3

1.3. Analysis

Comparison 1: Occlusion in all bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 3: Occlusion in all bypasses, 12 months

1.4

1.4. Analysis

Comparison 1: Occlusion in all bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 4: Occlusion in all bypasses, 24 months

1.5

1.5. Analysis

Comparison 1: Occlusion in all bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 5: Occlusion in all bypasses, 5 years

2.1

2.1. Analysis

Comparison 2: Limb loss in all bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 1: Limb loss in all bypasses, 3 months

2.2

2.2. Analysis

Comparison 2: Limb loss in all bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 2: Limb loss in all bypasses, 6 months

2.3

2.3. Analysis

Comparison 2: Limb loss in all bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 3: Limb loss in all bypasses, 12 months

2.4

2.4. Analysis

Comparison 2: Limb loss in all bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 4: Limb loss in all bypasses, 24 months

2.5

2.5. Analysis

Comparison 2: Limb loss in all bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 5: Limb loss in all bypasses, 5 years

3.1

3.1. Analysis

Comparison 3: Deaths in all bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 1: Deaths in all bypasses, 3 months

3.2

3.2. Analysis

Comparison 3: Deaths in all bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 2: Deaths in all bypasses, 6 months

3.3

3.3. Analysis

Comparison 3: Deaths in all bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 3: Deaths in all bypasses, 12 months

3.4

3.4. Analysis

Comparison 3: Deaths in all bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 4: Deaths in all bypasses, 24 months

3.5

3.5. Analysis

Comparison 3: Deaths in all bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 5: Deaths in all bypasses, 5 years

4.1

4.1. Analysis

Comparison 4: Occlusion in venous bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 1: Occlusion in venous bypasses, 3 months

4.2

4.2. Analysis

Comparison 4: Occlusion in venous bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 2: Occlusion in venous bypasses, 6 months

4.3

4.3. Analysis

Comparison 4: Occlusion in venous bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 3: Occlusion in venous bypasses, 12 months

4.4

4.4. Analysis

Comparison 4: Occlusion in venous bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 4: Occlusion in venous bypasses, 24 months

4.5

4.5. Analysis

Comparison 4: Occlusion in venous bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 5: Occlusion in venous bypasses, 5 years

5.1

5.1. Analysis

Comparison 5: Limb loss in venous bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 1: Limb loss in venous bypasses, 3 months

5.2

5.2. Analysis

Comparison 5: Limb loss in venous bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 2: Limb loss in venous bypasses, 6 months

5.3

5.3. Analysis

Comparison 5: Limb loss in venous bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 3: Limb loss in venous bypasses, 12 months

5.4

5.4. Analysis

Comparison 5: Limb loss in venous bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 4: Limb loss in venous bypasses, 24 months

5.5

5.5. Analysis

Comparison 5: Limb loss in venous bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 5: Limb loss in venous bypasses, 5 years

6.1

6.1. Analysis

Comparison 6: Limb salvage venous grafts, vitamin K antagonist (VKA) versus no VKA, Outcome 1: Limb salvage 6 months

7.1

7.1. Analysis

Comparison 7: Deaths in venous bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 1: Deaths in venous bypasses, 3 months

7.2

7.2. Analysis

Comparison 7: Deaths in venous bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 2: Deaths in venous bypasses, 6 months

7.3

7.3. Analysis

Comparison 7: Deaths in venous bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 3: Deaths in venous bypasses, 12 months

7.4

7.4. Analysis

Comparison 7: Deaths in venous bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 4: Deaths in venous bypasses, 24 months

7.5

7.5. Analysis

Comparison 7: Deaths in venous bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 5: Deaths in venous bypasses, 5 years

8.1

8.1. Analysis

Comparison 8: Occlusion in artificial bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 1: Occlusion in artificial bypasses, 3 months

8.2

8.2. Analysis

Comparison 8: Occlusion in artificial bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 2: Occlusion in artificial bypasses, 6 months

8.3

8.3. Analysis

Comparison 8: Occlusion in artificial bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 3: Occlusion in artificial bypasses, 12 months

8.4

8.4. Analysis

Comparison 8: Occlusion in artificial bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 4: Occlusion in artificial bypasses, 24 months

8.5

8.5. Analysis

Comparison 8: Occlusion in artificial bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 5: Occlusion in artificial bypasses, 5 years

9.1

9.1. Analysis

Comparison 9: Limb loss in artificial bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 1: Limb loss in artificial bypasses, 3 months

9.2

9.2. Analysis

Comparison 9: Limb loss in artificial bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 2: Limb loss in artificial bypasses, 6 months

9.3

9.3. Analysis

Comparison 9: Limb loss in artificial bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 3: Limb loss in artificial bypasses, 12 months

9.4

9.4. Analysis

Comparison 9: Limb loss in artificial bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 4: Limb loss in artificial bypasses, 24 months

9.5

9.5. Analysis

Comparison 9: Limb loss in artificial bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 5: Limb loss in artificial bypasses, 5 years

10.1

10.1. Analysis

Comparison 10: Deaths in artificial bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 1: Deaths in artificial bypasses, 3 months

10.2

10.2. Analysis

Comparison 10: Deaths in artificial bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 2: Deaths in artificial bypasses, 6 months

10.3

10.3. Analysis

Comparison 10: Deaths in artificial bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 3: Deaths in artificial bypasses, 12 months

10.4

10.4. Analysis

Comparison 10: Deaths in artificial bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 4: Deaths in artificial bypasses, 24 months

10.5

10.5. Analysis

Comparison 10: Deaths in artificial bypasses, vitamin K antagonist (VKA) versus no VKA, Outcome 5: Deaths in artificial bypasses, 5 years

11.1

11.1. Analysis

Comparison 11: Occlusion in all bypasses, vitamin K antagonist (VKA) versus ASA/DIP, Outcome 1: Occlusion in all bypasses, 3 months

11.2

11.2. Analysis

Comparison 11: Occlusion in all bypasses, vitamin K antagonist (VKA) versus ASA/DIP, Outcome 2: Occlusion in all bypasses, 6 months

11.3

11.3. Analysis

Comparison 11: Occlusion in all bypasses, vitamin K antagonist (VKA) versus ASA/DIP, Outcome 3: Occlusion in all bypasses, 12 months

11.4

11.4. Analysis

Comparison 11: Occlusion in all bypasses, vitamin K antagonist (VKA) versus ASA/DIP, Outcome 4: Occlusion in all bypasses, 24 months

12.1

12.1. Analysis

Comparison 12: Occlusion in venous bypasses, vitamin K antagonist (VKA) versus ASA/DIP, Outcome 1: Occlusion in venous bypasses, 3 months

12.2

12.2. Analysis

Comparison 12: Occlusion in venous bypasses, vitamin K antagonist (VKA) versus ASA/DIP, Outcome 2: Occlusion in venous bypasses, 6 months

12.3

12.3. Analysis

Comparison 12: Occlusion in venous bypasses, vitamin K antagonist (VKA) versus ASA/DIP, Outcome 3: Occlusion in venous bypasses, 12 months

12.4

12.4. Analysis

Comparison 12: Occlusion in venous bypasses, vitamin K antagonist (VKA) versus ASA/DIP, Outcome 4: Occlusion in venous bypasses, 24 months

13.1

13.1. Analysis

Comparison 13: Occlusion in artificial bypasses, vitamin K antagonist (VKA) versus ASA/DIP, Outcome 1: Occlusion in non‐venous bypasses, 3 months

13.2

13.2. Analysis

Comparison 13: Occlusion in artificial bypasses, vitamin K antagonist (VKA) versus ASA/DIP, Outcome 2: Occlusion in non‐venous bypasses, 6 months

13.3

13.3. Analysis

Comparison 13: Occlusion in artificial bypasses, vitamin K antagonist (VKA) versus ASA/DIP, Outcome 3: Occlusion in non‐venous bypasses, 12 months

13.4

13.4. Analysis

Comparison 13: Occlusion in artificial bypasses, vitamin K antagonist (VKA) versus ASA/DIP, Outcome 4: Occlusion in non‐venous bypasses, 24 months

14.1

14.1. Analysis

Comparison 14: Occlusion in all bypasses, low molecular weight heparin (LMWH) versus unfractionated heparin (UFH), Outcome 1: Occlusion in all bypasses, 24 hours

14.2

14.2. Analysis

Comparison 14: Occlusion in all bypasses, low molecular weight heparin (LMWH) versus unfractionated heparin (UFH), Outcome 2: Occlusion in all bypasses, day 10

14.3

14.3. Analysis

Comparison 14: Occlusion in all bypasses, low molecular weight heparin (LMWH) versus unfractionated heparin (UFH), Outcome 3: Occlusion,in all bypasses, day 30

14.4

14.4. Analysis

Comparison 14: Occlusion in all bypasses, low molecular weight heparin (LMWH) versus unfractionated heparin (UFH), Outcome 4: Per protocol

15.1

15.1. Analysis

Comparison 15: Occlusion in all bypasses, low molecular weight heparin (LMWH) versus ASA/DIP, Outcome 1: Occlusion in all bypasses, 6 months

15.2

15.2. Analysis

Comparison 15: Occlusion in all bypasses, low molecular weight heparin (LMWH) versus ASA/DIP, Outcome 2: Occlusion in all bypasses, 12 months

16.1

16.1. Analysis

Comparison 16: Occlusion in all bypassess, low molecular weight heparin (LMWH) versus no LMWH, Outcome 1: Occlusion in all bypasses, 1 month

16.2

16.2. Analysis

Comparison 16: Occlusion in all bypassess, low molecular weight heparin (LMWH) versus no LMWH, Outcome 2: Occlusion in all bypasses, 3 months

16.3

16.3. Analysis

Comparison 16: Occlusion in all bypassess, low molecular weight heparin (LMWH) versus no LMWH, Outcome 3: Occlusion in all bypasses, 12 months

17.1

17.1. Analysis

Comparison 17: Survival venous grafts, Sarac study, Outcome 1: Survival 6 months, intention to treat

17.2

17.2. Analysis

Comparison 17: Survival venous grafts, Sarac study, Outcome 2: Survival 2 years, intention to treat

18.1

18.1. Analysis

Comparison 18: Early graft thrombosis, ancrod versus heparin, Outcome 1: Early graft thrombosis, 24 h and 1 month

19.1

19.1. Analysis

Comparison 19: Early graft thrombosis, unfractionated heparin (UFH) versus antithrombin, Outcome 1: Antithrombin versus UFH, intraoperative graft thrombosis

19.2

19.2. Analysis

Comparison 19: Early graft thrombosis, unfractionated heparin (UFH) versus antithrombin, Outcome 2: Antithrombin versus UFH, 1 month occlusion (following thrombendarterectomy)

20.1

20.1. Analysis

Comparison 20: Early graft occlusion, low molecular weight heparin (LMWH) versus dextran, Outcome 1: Early graft occlusion, 30 days

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References

References to studies included in this review

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Alja‐Kulju 1990 {published data only}
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References to other published versions of this review

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