Short-Term Outcomes of Dual Versus Single Antiplatelet Therapy Following Popliteal and Infrapopliteal Endovascular Therapy: Data From Dutch Chronic Lower Limb-Threatening Ischemia Registry (THRILLER)
Authors: Wegerif Emilien C. J. , Nugteren Michael J. , van Galen Isa F. , Hazenberg Constantijn E. V. B. , Schreve Michiel A. , Akkersdijk George P. , Fioole Bram , Pierie Maurice , Schouten Olaf , van den Heuvel Daniel A. F. , Bakker Olaf J. , Hinnen Jan-Willem , Verhoeven Bart A. N. , Heyligers Jan M. M. , Dinkelman Maarten K. , de Borst Gert J. , Ünlü Çağdaş 
Published: January 2025

Objective: There is a lack of consensus regarding the optimal antithrombotic therapy (ATT) after popliteal and infrapopliteal (PIP) endovascular therapy (EVT). Currently, dual antiplatelet therapy (DAPT) for 3 months and single antiplatelet therapy (SAPT) are the most prescribed regimens in the Netherlands. Thus far, no randomized comparison has been performed on the optimal ATT approach. Therefore, this study compared the efficacy and safety of 3-month DAPT with SAPT following PIP EVT. Design: Retrospective analysis of prospectively collected data from a multicenter registry. Methods: The Dutch chronic lower limb-threatening ischemia registry (THRILLER) collected prospective data on patients enrolled between January 2021 and October 2023. As for ATT, only patients prescribed antiplatelet therapy (APT), were included in this analysis. The primary efficacy outcome was a composite of 3-month major adverse cardiovascular events (MACEs, ie, myocardial infarction, cerebrovascular event, cardiovascular death), major adverse limb events (MALEs, ie, major amputation, reintervention), and non-cardiovascular death. Secondary efficacy outcomes were 3-month MACE, MALE, and all-cause mortality. The primary safety outcome was major bleeding according to the ‘Thrombolysis In Myocardial Infarction’ (TIMI) classification. Descriptive statistics and Cox proportional hazard models were applied. Results: In total, 460 of 840 THRILLER patients used DAPT or SAPT as ATT and were therefore included in the analysis. Of these, 322 (70%) received DAPT and 138 (30%) received SAPT. In total, 73 (15.9%) primary efficacy outcomes were observed of which 21 (15.2%) events in the SAPT group and 52 (16.1%) events in the DAPT group. No significant differences were observed between SAPT and DAPT for the primary efficacy outcomes or any of the secondary efficacy outcomes. In both groups, one case of major bleeding was observed. Conclusion: The findings suggest that 3 months of DAPT is not superior to SAPT. A well-powered randomized trial is warranted to assess the efficacy and safety of post-procedural DAPT in chronic limb-threatening ischemia (CLTI) patients undergoing PIP EVT. Clinical Impact This manuscript reports on the efficacy and safety outcomes of 3 months of DAPT versus SAPT, which are commonly chosen therapies following popliteal and infrapopliteal endovascular therapy. No significant difference was found between the two groups regarding major adverse cardiovascular events, all-cause death, major amputation, or major bleeding. Therefore, 3 months of DAPT does not seem superior to SAPT. These results suggest that SAPT appears to be a sufficient alternative when considering 3 months of DAPT. Further research should verify these outcomes and focus on the efficacy and safety of prolonged DAPT suppletion after endovascular therapy.