Clinical trial NCT02230527
Conditions: Peripheral Arterial Disease
Sponsor: The Cleveland Clinic
Start date: 2014-10-01; Completion date: 2020-05-01
Enrollment: 46 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
This is a single center, prospective, randomized, unblinded, open-label, active controlled pilot study to evaluate the efficacy and safety of ticagrelor plus aspirin versus clopidogrel plus aspirin in patients with Rutherford Stage IV to VI PAD that have undergone a percutaneous transluminal angioplasty (PTA) of the lower extremities in the past 2 weeks.

Detailed description:
Enrollment into the study will require severe symptomatic CLI without wounds (Rutherford Stage IV) or CLI with concomitant vascular insufficiency wounds (Rutherford Stage V-VI PAD).

Potential participants will be identified and screened prior to discharge or at the time of the first out-patient visit (within 2 weeks after discharge) after a percutaneous lower extremity arterial angiography with arterial intervention (stent or balloon angioplasty) for the presence of lower extremity vascular insufficiency. Participants will be classified as Rutherford Class IV - VI (with or without ulcerations). A total of 60 patients will be randomized into 2 treatment groups in a 1:1 ratio (ticagrelor to clopidogrel). Patients are placed on clopidogrel after their arterial intervention per standard of care. They will remain on clopidogrel up to the time that randomization occurs. For patients that are randomized to ticagrelor, the clopidogrel will be stopped.

Patients will be randomized to either ticagrelor 90mg by mouth twice daily or clopidogrel 75mg by mouth daily.

Arms: arm 1: Clopidogrel 75mg by mouth daily arm 2: Ticagrelor 90mg by mouth twice daily
Interventions: intervention 1: Ticagrelor intervention 2: Clopidogrel
Intervention descriptions: intervention 1: 90mg twice a day by mouth intervention 2: 75mg once a day by mouth

Protocol documents:
Prot_SAP_000.pdf: 
Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 1 
 
 
 
 
Establishing the microcirculatory effects of ticagrelor on tissue 
perfusion in critical limb ischemia 
 
 
 
Version Date:  September 21, 2017 
 
Protocol Number:  Version 4.0 
 
Protocol Amendment #3 
 
 
 
Sponsor:  Mehdi H. Shishehbor, D.O., M.P.H. 
 
 
 
 
Funding: A grant from AstraZeneca  
 
 
 
 
Primary Investigator:  Mehdi H. Shishehbor, D.O., M.P.H. 
 
 
 
 
 
 
 
 
 
 
 
 
 
This investigational protocol contains confidential information for use by the principal 
investigators and their designated representatives participating in this clinical investigation.  It 
should be held confidential and maintained in a secure location.  It should not be copied or made 
available for review by any unauthorized person or firm


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 2 
 
 
 
Protocol Signature Page 
 
 
Establishing the microcirculatory effects of ticagrelor on tissue perfusion in critical limb 
ischemia 
 
Version date:  September 21, 2017 
 
Protocol Number:  Version 4.0 
 
Protocol Amendment #3 
 
 
I have carefully read “Establishing the microcirculatory effects of ticagrelor on tissue perfusion 
in critical limb ischemia”.  I agree to conduct this study as outlined herein. 
 
 
 
 
_________________________ 
Investigator Signature 
 
 
_________________________ 
Printed Investigator Name 
 
 
_________________________ 
Date 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 3 
 
 
 
Table of Content 
1 
Introduction 
12 
1.1 
Background 
12 
1.2 
Rationale for use of ticagrelor 
12 
1.3 
Rationale for use of TcPO2 and SPP 
13 
2 
Study Design 
13 
2.1 
Summary 
14 
3 
Study Objectives and Endpoints 
14 
3.1 
Primary Objective 
14 
3.2 
Study Endpoints 
14 
3.2.1 
Primary Endpoint 
14 
3.2.2 
Secondary Endpoints 
14 
4 
Selection and Withdrawal of Patients 
14 
4.1 
Study Population 
14 
4.1.1 
Inclusion Criteria 
15 
4.1.2 
Exclusion Criteria 
15 
4.2 
Patient Enrollment and Randomization 
16 
4.3 
Study Withdrawal 
16 
4.4 
Study Discontinuation 
16 
5 
Treatment of Patients 
16 
5.1 
Treatment Regimen 
16 
5.2 
Description of Study Drug 
17 
5.3 
Obtaining Study Drugs 
17 
5.4 
Concomitant Medications 
17 
5.5 
Prohibited Medications 
17 
6 
Study Procedures 
17 
6.1 
Screening/Baseline 
17 
6.2 
Month 3 follow up 
18 
6.3 
Month 6 follow up 
18 
6.4 
Study Procedures 
19 
6.4.1 
Demographics and Medical History 
19 
6.4.2 
Measurement of TcPO2 
19 
6.4.3 
Measurement of Skin Perfusion Pressure 
20 
6.4.4 
Ankle-Brachial Index 
20 
6.4.5 
Toe-Brachial Index and Toe-Systolic Pressure 
20 
7 
Pharmacologic Loading Pre-revascularization 
21 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 4 
 
 
 
8 
Safety Monitoring and Reporting 
21 
8.1 
Adverse Events 
21 
8.2 
Serious Adverse Events 
21 
8.3 
Other Events of Special Interest Considered as Serious 
22 
8.4 
Documentation and Reporting of Adverse Events 
22 
8.5 
Safety Monitoring 
23 
9 
Statistical Plan 
23 
9.1 
Statistical Methods 
23 
9.2 
Sample size 
23 
10 
Study Committees 
24 
10.1 
Executive Steering Committee 
24 
10.2 
Safety Monitoring Board 
24 
11 
Data Handling and Record Keeping 
24 
11.1 
Data Collection 
25 
11.2 
REDCap Database: 
25 
11.3 
REDCap Completion Guidelines: 
25 
11.4 
Retention of Records 
25 
12 
Study Monitoring, Auditing, and Inspecting 
25 
13 
Ethical Considerations 
26 
14 
Publication 
26 
15 
References 
27 
Appendix A 
29 
Appendix B 
48 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 5 
 
 
 
 
List of Abbreviations 
 
ABI 
Ankle-Brachial Index 
ACS 
Acute Coronary Syndrome 
AE 
Adverse Event 
ANOVA 
Analysis of Variance 
B/P 
Blood Pressure 
BUN 
Blood Urea Nitrogen 
CFR 
Code of Federal Regulations 
CKD 
Chronic Kidney Disease 
CLI 
Critical Limb Ischemia 
COPD 
Chronic Obstructive Pulmonary Disease 
Crt 
Creatinine 
CVA 
Cerebrovascular Accident 
DAPT 
Dual Antiplatelet Therapy 
DM 
Data Management 
eCRF 
Electronic Case Report Form 
ESC 
Executive Steering Committee 
FDA 
Food and Drug Administration 
HbA1c 
Hemoglobin A1c 
Hct 
Hematocrit 
HDL 
High-Density Lipoprotein 
Hgb 
Hemoglobin 
HR 
Heart Rate 
INR 
International Normalized Ratio 
IRB 
Institutional Review Board 
ISS 
Investigator Sponsored Study 
LDL 
Low-Density Lipoprotein 
LS 
Least Squares 
mg 
milligrams 
mmHg 
Millimeters Mercury 
MMRM 
Mixed Model Repeated Measures  
PAD 
Peripheral Arterial Disease 
Plt 
Platelet Count 
PTA 
Percutaneous Transluminal Angioplasty 
PTT 
Partial Thromboplastin Time 
REDCap 
Research Electronic Data Capture 
SAE 
Serious Adverse Event 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 6 
 
 
 
SAS 
Statistical Analysis System 
SD 
Standard Deviation 
SOC 
Standard of Care 
SPSS 
Statistical Package for the Social Sciences 
SSL 
Secure Sockets Layer 
SPP 
Skin Perfusion Pressure 
TBI 
Toe-Brachial Index 
Tchol 
Total Cholesterol 
TcPO2 
Transcutaneous Oxygen Concentration 
Tg 
Triglycerides 
TIA 
Transient Ischemic Attack 
TSP 
Toe-Systolic Pressure 
ULN 
Upper Limit of Normal 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 7 
 
 
 
 
Study Synopsis 
 
Title 
Establishing the microcirculatory effects of ticagrelor on tissue perfusion in 
critical limb ischemia 
Sponsor  
Mehdi H. Shishehbor, D.O., M.P.H. 
Rationale  
Ticagrelor has emerged as a novel P2Y12 adenosine receptor antagonist 
studied primarily in the treatment of coronary heart disease, but with 
properties that make the drug suitable for study in PAD.  Beyond its 
antiplatelet effects, ticagrelor’s ability to inhibit uptake of adenosine may 
provide cytoprotective and reparative properties that could prove 
therapeutic to patients with advanced PAD.   Indeed, oral administration of 
ticagrelor to animals prevents contraction of vascular smooth muscle: an 
effect not seen with clopidogrel or prasugrel (5). Similar to effects seen with 
clopidogrel, ticagrelor may reduce leukocyte-platelet adhesion and improve 
microcirculatory function during ischemia by reducing blood viscosity (6).  
In addition to these beneficial antiplatelet effects, ticagrelor may provide 
additional benefit in smooth muscle relaxation by promoting serum 
adenosine concentrations. 
Study Center 
Cleveland Clinic and University Hospital in Cleveland 
Indication 
Rutherford Classification Stage IV through VI PAD 
Study 
Objectives 
The primary goal of the proposed research is to determine if ticagrelor can 
induce a clinically significant change in transcutaneous oxygen 
concentration (TcPO2) superior to that induced by clopidogrel, among 
advanced cases of recently revascularized peripheral arterial disease (PAD).   
 
Secondary objectives include: 
 1) to compare the rate of wound healing at 6 months between treatment 
groups among Rutherford Classification Stage V-VI patients 
 2) to determine if other markers of blood flow improve with treatment with 
ticagrelor. 
Study Design 
This is a 2-arm randomized, active-controlled, pilot study.  Patients over the 
age of 18 presenting with Rutherford Classification Stage IV-VI PAD will 
be included. Sixty (N=60) eligible patients who have given their consent to 
participate will be randomized to one of the following treatments: 
 
 Clopidogrel (75 mg by mouth daily) 
 Ticagrelor (90 mg by mouth twice daily) 
 
All patients will be followed for 6 months after enrollment, with the 
primary endpoint assessed at 6 months after randomization. 
Number of 
Patients 
A sample size of 60 patients (30 per group) provides 90% power to detect  
an 8±8 mmHg difference in TcPO2 between groups. 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 8 
 
 
 
Target 
Population 
Patients with critical limb ischemia either Rutherford Stage IV (without 
wounds) or Stage V-VI (with concomitant vascular insufficiency wounds) 
that have been recently revascularized. 
Duration of 
patient 
participation 
and duration of 
the study  
The total duration of the study is expected to be 54 months including 48 
months for patient recruitment and 6 months for final patient follow-up.  
Patients will participate in the study for approximately 6 months.   
Key Selection 
Criteria 
INCLUSION CRITERIA 
 Adults age 18-100 years with Rutherford Classification Stage IV 
through VI PAD with a percutaneous lower extremity arterial 
angiography with arterial intervention in the past 2 weeks 
 Willingness to sign informed consent 
 Ability to return for follow-up visits 
 A female patient of childbearing potential who is sexually active 
must agree to use adequate contraception from screening until 30 
days after receiving the last dose of study drug. 
EXCLUSION CRITERIA 
 Intolerance to thienopyridines 
 Hypersensitivity to ticagrelor or any component of the product 
 Concomitant use of oral anticoagulation with vitamin K antagonist, 
factor Xa inhibitor, or direct thrombin inhibitor 
 History  of intracranial hemorrhage 
 History of severe hepatic impairment defined by baseline 
transaminase greater than or equal to 3x ULN or any elevation in 
bilirubin 
 Active bleeding 
 Allergy to aspirin 
 Baseline TcPO2 < 10 mmHg post angiography 
 Resting pre-procedure heart rate < 50 beats-per-minute without a 
permanent pacemaker and not on an atrioventricular nodal blocking 
agent 
 Severe COPD on home oxygen therapy 
 Patients on strong CYP3A inhibitors and/or CYP3A inducers that 
cannot be stopped for the course of the study.   
Study Visit 
Schedule and 
Assessments 
Visits will occur at screening (baseline) post angiography, and at 3 and 6 
months. 
Test Product, 
Dose, and 
Mode of 
Administration 
Patients will be randomized to either ticagrelor 90 mg by mouth twice daily 
or clopidogrel 75 mg by mouth daily. 
 
 
Concomitant  
Medications 
Aspirin 81 mg by mouth every day 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 9 
 
 
 
Prohibited 
Medications  
 Concomitant use of oral anticoagulation with a vitamin K 
antagonist, factor Xa inhibitor, or direct thrombin inhibitor 
 Aspirin > 100mg per day 
Endpoints  
Primary endpoint 
 Absolute change in TcPO2 from baseline to 6 months  
 
Secondary endpoints 
 Rate of wound healing from baseline to month 6 in treatment groups 
for patients with Rutherford Stage V-VI PAD 
 Change in ankle-brachial index (ABI), toe-brachial index (TBI),  
toe-systolic pressure (TSP) and skin perfusion pressure (SPP) from 
baseline to month 6 in treatment groups 
 Major adverse limb events including a composite of surgical limb 
loss or any major vascular repeat revascularization, including 
thrombectomy, thrombolysis, or major lower-extremity surgical 
procedure from baseline to month 6 in treatment groups 
 Percent change in TcPO2 from baseline to 6 months 
 Percent change and absolute change in TcPO2 from baseline to 
month 3 
AE/ SAE 
Collection 
AEs 
 Self-reported shortness of breath with symptomatic bradycardia 
 Events that are not listed in the current labeling for the drugs  
 Events that lead to discontinuation of drug or result in a dose 
modification 
SAEs 
 Death. 
 Life threatening AEs. 
 Requires inpatient hospitalization or prolongation of existing 
hospitalization. 
 A disability/incapacity. 
 A congenital anomaly/birth defect in the offspring of a patient who 
received drug. 
 Important medical event that may jeopardize the subject or may 
require medical intervention to prevent one of the outcomes listed 
above. 
 
Other SAEs of Special Interest 
 Major bleeding defined as a composite of fatal bleeding, intracranial 
bleeding, hypovolemic shock or severe hypotension due to bleeding 
requiring pressors, or need for transfusion of at least 2 units in any 
24-hour period.   
 Major adverse limb events (surgical limb loss, major repeat 
revascularizations including thrombectomy, thrombolysis, or major 
lower extremity surgical procedure. 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
10 
 
 
 
Safety 
Evaluations  
Safety endpoints to be assessed include major bleeding, self-reported 
dyspnea and reported symptomatic bradycardia. 
Statistical 
Methodology 
Analysis of the Primary and Secondary Endpoints 
 
     Baseline covariates will be compared with Fisher’s exact test for 
categorical variables and two-sample t-test for continuous variables with a 
normal distribution or rank sum test if non-normally distributed between 
treatment groups.  All comparisons between treatment groups will be 
performed as intent-to-treat using two-tailed significance testing at a value 
of 0.05. 
      Mixed model repeated measures analysis (MMRM) will be used to 
conduct the between-group comparison of absolute change in TcPO2 at 3 
months and 6 months follow-up, with adjustment of baseline TcPO2 level 
following revascularization. Estimated within-group least squares (LS) 
means of TcPO2 and between-group differences of LS means in TcPO2 at 
3- and at 6-month follow-up time points will be obtained from the MMRM 
modeling.   
      If the TcPO2 data is not normally distributed, the same MMRM method 
will be performed to analyze the rank transformed TcPO2 data, however the 
descriptive data is presented with median (interquartile range), and the 
between-group differences are shown using F statistics. Meanwhile, 
relevant nonparametric methods will be applied as sensitivity analysis. 
Friedman test will be conducted to compare the TcPO2 repeated measures 
from baseline to 6 months follow-up between the treatment groups. A 
Wilcoxon signed rank test will be used to assess intragroup change in 
TcPO2 at 3- and at 6-month follow-up.    
      The absolute change in TcPO2 over time and other continuous 
secondary endpoints will be analyzed using the same strategies. Safety 
endpoints, adverse events and other categorical secondary endpoints will be 
analyzed using Fisher’s exact test. The relationships between the primary 
endpoint of change in TcPO2 at 6 months follow-up and the continuous 
secondary endpoints will be explored by regression analysis.   
 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
11 
 
 
 
 
Study Visits 
Study Procedures 
Screening/ 
Baseline 
3 Months 
(+/- 1 
week) 
6 Months 
(+/- 1 
week) 
Informed Consent 
X 
 
 
Demographics 
X 
 
 
Medical History 
X 
 
 
Rutherford 
Classification 
X 
X 
X 
ABI, TBI, TSP 
X 
X 
X 
Wound Size 
X 
X 
X 
Vital Signs 
X 
X 
X 
Record Baseline 
Labs¹  
X 
 
 
Urine Pregnancy 
Test² 
X 
 
 
Angiographic Data 
X 
 
 
TcPO2 measurement X³ 
X 
X 
SPP measurement  
X 
X 
X 
Concomitant 
Medications 
X 
X 
X 
Randomization 
X 
 
 
Dispense Study 
Drug 
X 
X 
 
Assessment of 
wound healing 
 
X 
X 
Study medication 
compliance 
 
X 
X 
Collect AEs & SAEs  
X 
X 
 
¹Baseline labs will be obtained from local labs performed in the month prior to screening and 
include the following: Blood urea nitrogen, creatinine, HbA1c, hemoglobin, hematocrit, platelet 
count, international normalized ratio, partial thromboplastin time, total cholesterol, low-density 
lipoprotein, high-density lipoprotein, triglycerides 
²For females of childbearing potential 
³Post angiography 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
12 
 
 
 
1 
Introduction 
 
1.1 
Background 
Treatment of critical limb ischemia (CLI), an advanced form of peripheral arterial disease 
(PAD), has lagged behind other forms of cardiovascular disease. Lacking are novel medical 
strategies that promote ambulatory ability and, when CLI-related wounds are present, 
reconstitution of tissue oxygenation and tissue healing.  Wound healing remains a distinct 
challenge, characterized by a complex interplay of neuropathic and microvascular circulatory 
deficiencies that promote inflammation and tissue hypoxia (1).  Recent interest has focused on 
the role of adenosine, a ubiquitous purine nucleoside, and its reparative biological effects 
through neuromodulation and wound healing via A (2A) and A (2B) cellular receptors (2,3).  
Herein, we propose a first-in-man pilot study among patients revascularized for advanced 
symptomatic PAD, including patients with CLI-related vascular insufficiency wounds.  
Ticagrelor will be compared to clopidogrel, the post-angioplasty standard-of-care thienopyridine, 
in an evaluation of interval improvement in tissue oxygenation as assessed by tissue partial 
pressure of oxygen (TcPO2). 
 
1.2 
Rationale for use of ticagrelor 
Ticagrelor has emerged as a novel P2Y12 adenosine receptor antagonist studied primarily 
in the treatment of coronary heart disease, but with properties that make the drug suitable for 
study in PAD.  Beyond its antiplatelet effects, ticagrelor’s ability to inhibit uptake of adenosine 
may provide cytoprotective and reparative properties that could prove therapeutic to patients 
with advanced PAD.  These beneficial properties may explain the striking reduction of adverse 
vascular outcomes observed in the PLATO Study and may represent a fundamental 
pharmacologic difference between ticagrelor – a carbocyclic nucleoside – and the 
thienopyridines (4).  Indeed, oral administration of ticagrelor to animals prevents contraction of 
vascular smooth muscle: an effect not seen with clopidogrel or prasugrel (5). Similar to effects 
seen with clopidogrel, ticagrelor may reduce leukocyte-platelet adhesion and improve 
microcirculatory function during ischemia by reducing blood viscosity (6).  In addition to these 
beneficial antiplatelet effects, ticagrelor may provide additional benefit in smooth muscle 
relaxation by promoting serum adenosine concentrations.  In addition to its vasodilatory 
properties, adenosine has been shown to limit ischemia-related tissue injury.  The addition of 
adenosine to thrombolytic therapy in acute myocardial infarction in 3 large randomized studies 
has demonstrated dramatic reduction in infarct size (7-9).   To this end, a randomized, double-
blind, phase IIIb multicenter study is underway comparing cardiovascular outcomes among an 
anticipated 11,500 patients with established PAD in the Examining Use of tiCagrelor In paD 
(EUCLID) Study (clinicaltrials.gov Identifier: NCT01732822).  While this large clinical 
outcomes study is timely and highly important, a study demonstrating ticagrelor’s microvascular 
effects is warranted.  Ticagrelor’s potentially beneficial pharmacologic properties may offer 
advantages of increased tissue oxygenation that promote wound healing and improve ambulatory 
ability in advanced PAD.  
 Similar to the endovascular treatment of coronary artery disease, percutaneous 
transluminal angioplasty (PTA) for PAD requires the use of dual-antiplatelet therapy (DAPT) to 
prevent thrombotic complications related to stent placement or balloon angioplasty.  In a head-
to-head comparison with clopidogrel among patients with acute coronary syndromes, ticagrelor 
has already shown impressive reductions in mortality without increasing the overall risk of major 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
13 
 
 
 
bleeding (13).   For patients undergoing PTA, DAPT is recommended for at least 30 days 
following the PTA procedure. The benefits of DAPT beyond 30-days after peripheral arterial 
intervention have been recently demonstrated; clopidogrel plus aspirin was superior to aspirin 
monotherapy for up to 6 months after PTA by preventing peri-procedural platelet activation and 
improved functional outcomes without increasing the risk of bleeding complications (14).  
Furthermore, even though costs associated with long-term DAPT are higher, clopidogrel has 
proven cost-effective over aspirin monotherapy for secondary prevention for vascular events 
among patients with PAD (15,16).   With an anticipated antiplatelet benefit as robust as that of 
clopidogrel, ticagrelor may also demonstrate cost-effectiveness.  
 
1.3 
Rationale for use of TcPO2 and SPP  
To assess the potential perfusion benefits of ticagrelor, baseline and follow-up assessment 
with TcPO2 will be used to compare relative effects of clopidogrel.  TcPO2 requires cutaneous 
positioning of oximetry electrodes and has been validated as an appropriate clinical measure of 
tissue oxygenation in CLI (10).   A distinct advantage of TcPO2 includes its ability to assess 
regional tissue oxygenation, such as at the external margins of a vascular insufficiency ulcer.  
TcPO2 also provides surrogate information of macro- and microvascular arterial perfusion with a 
prognostic signal; TcPO2 levels > 30 mmHg have been associated with higher rates of local 
wound healing (10,11).     
Several noninvasive measures of local tissue perfusion provide complementary roles in 
management of patients with wounds related to tissue ischemia.  Whereas ankle-brachial index 
(ABI) is a valid screening tool for PAD, advanced vascular calcification that often accompanies 
severe PAD also renders ABI less reliable, often by underestimating disease severity. Markers of 
microvascular perfusion, such as toe-brachial index, toe systolic pressure, TcPO2 and skin 
perfusion pressure have been suggested to be more accurate measures.  TcPO2 may have 
improved accuracy in predicting wound healing relative to other modalities, including toe 
systolic pressure (TSP) (12). However, there exist no simultaneous comparisons of all four 
techniques among patients with advanced PAD.   Therefore, an important feature of this study is 
to compare these techniques among patients with Rutherford Class IV-VI CLI. 
Alternate noninvasive techniques to assess arterial flow in CLI have important limitations.  
Ankle-brachial index is the standard noninvasive test for PAD, although it can provide unreliable 
and overestimated results among those with advanced age, diabetes mellitus, and chronic kidney 
disease (10,11,17).  Toe-blood pressure, including TBI and TSP, while prognostically useful in 
predicting wound healing, is not available among those with previous forefoot amputation.  For 
these reasons, TcPO2 was selected for this study as a reliable assessment of regional tissue 
oxygenation, sensitive to improvements in microvascular perfusion. Similar to TcPO2, the utility 
of SPP has not been extensively characterized, although some studies suggest it is useful in 
assessing perivascular microcirculation of the wound (11).  Distinct from the assessment of 
tissue oxygenation with TcPO2, SPP measures blood in the microcirculation around and within a 
wound. SPP is a painless test that measures microcirculatory blood flow using 
photoplethysmography with Doppler techniques. Therefore, SPP offers a complimentary and 
concurrent assessment of microcirculatory wound perfusion that may enhance understanding of 
healing in ischemic tissues. 
 
2 
Study Design 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
14 
 
 
 
2.1 
Summary 
This is a prospective, randomized, unblinded, open-label, active controlled pilot study to 
evaluate the efficacy and safety of ticagrelor plus aspirin versus clopidogrel plus aspirin in 
patients with Rutherford Stage IV to VI PAD that have undergone a percutaneous transluminal 
angioplasty (PTA) of the lower extremities in the past 2 weeks. 
This study will be conducted at the Cleveland Clinic and University Hospital in Cleveland, Ohio.  
A total of 60 patients are planned for this study. 
 
3 
Study Objectives and Endpoints 
 
3.1 
Primary Objective 
The primary objective is to determine if ticagrelor, compared to clopidogrel, can induce a 
greater measurable change in transcutaneous oxygen concentration (TcPO2), a surrogate for 
tissue perfusion, among advanced cases of CLI.    
 
3.2 
Study Endpoints 
3.2.1 Primary Endpoint 
The primary endpoint is the absolute change in TcPO2 from baseline to month 6 
compared between treatment groups.  
3.2.2 Secondary Endpoints  
 Rate of wound healing from baseline to month 6 in treatment groups for patients with 
Rutherford Classification Stage V-VI PAD 
 Change in ankle-brachial index (ABI), toe-brachial index (TBI),  toe-systolic pressure (TSP) 
and skin perfusion pressure (SPP) from baseline to month 6 in treatment groups 
 Major adverse limb events including a composite of surgical limb loss or any major vascular 
repeat revascularization, including thrombectomy, thrombolysis, or major lower-extremity 
surgical procedure from baseline to month 6 in treatment groups 
 Percent change in TcPO2 from baseline to 6 months 
 Percent change and absolute change in TcPO2 from baseline to month 3 compared between 
treatment groups 
 
A subgroup analysis will be performed among patients with non-gangrenous wounds to include a 
secondary assessment comparing TcPO2 to changes in SPP, ABI, TBI, and TSP between 
treatment groups at baseline and over the course of the study.  
 
4 
Selection and Withdrawal of Patients 
 
4.1 
Study Population 
 
Approximately 60 patients who meet all inclusion criteria and no exclusion criteria will be 
randomized into the study. 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
15 
 
 
 
Enrollment into the study will require severe symptomatic CLI without wounds (Rutherford 
Stage IV) or CLI with concomitant vascular insufficiency wounds (Rutherford Stage V-VI 
PAD).   
Potential participants will be identified and screened prior to discharge or at the time of the first 
out-patient visit (within 2 weeks after discharge) after a percutaneous lower extremity arterial 
angiography with arterial intervention (stent or balloon angioplasty) for the presence of lower 
extremity vascular insufficiency. Participants will be classified as Rutherford Class IV – VI (with 
or without ulcerations). Per SOC, patients will have been placed on clopidogrel after the arterial 
intervention. 
4.1.1 Inclusion Criteria 
Eligible patients will be considered for inclusion in this study if they meet all of the 
following criteria:  
1. Adults age 18-100 years with Rutherford Classification Stage IV through VI PAD 
with a recent percutaneous lower extremity arterial angiography with arterial 
intervention in the past 2 weeks 
2. Willingness to sign informed consent 
3. Ability to return for follow-up visits 
4. A female patient of childbearing potential who is sexually active must agree to use 
adequate contraception from screening until 30 days after receiving the last dose of 
study drug. Women NOT of child bearing potential are defined as those who have 
been surgically sterilized (hysterectomy, bilateral oophorectomy, or tubal ligation) or 
who are postmenopausal (defined as at least 2 years since last regular menses).  The 
female patient should not be lactating and must have a negative pregnancy test at 
screening. 
4.1.2 Exclusion Criteria 
Patients will be ineligible for this study if they meet any one of the following criteria: 
1. Intolerance to thienopyridines 
2. Hypersensitivity to ticagrelor or any component of the product 
3. Concomitant use of oral anticoagulation with vitamin K antagonist, factor Xa 
inhibitor, or direct thrombin inhibitor 
4. History  of intracranial hemorrhage 
5. History of severe hepatic impairment defined by baseline transaminase greater than or 
equal to 3x ULN or any elevation in bilirubin 
6. Active bleeding 
7. Allergy to aspirin 
8. Baseline TcPO2 < 10 mmHg post angiography  
9. Resting pre-procedure heart rate < 50 beats-per-minute without a permanent 
pacemaker and not on an atrioventricular nodal blocking agent 
10. Severe COPD on home oxygen therapy 
11. Patients on strong CYP3A inhibitors and/or CYP3A inducers that cannot be stopped 
for the course of the study.  * 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
16 
 
 
 
*    Strong inhibitors of CYP3A are the following medications:  ketoconazole, itraconazole, 
voriconazole, clarithromycin, nefazodone, ritonavir, saquinavir, nelfinavir, indinavir, 
atazanavir and telithromycin. 
Potent inducers of CYP3A include the following medications:  rifampin, dexamethasone, 
phenytoin, carbamazepine and phenobarbital. 
In addition, ticagrelor will result in higher serum concentrations of simvastatin and lovastatin 
because these drugs are metabolized by CYP3A4 and doses greater than 40 mg with these 
medications should be avoided.   
 
4.2 
Patient Enrollment and Randomization 
 
Enrollment will occur when a patient signs and dates an informed consent form and provides 
authorization to use protected health information.   
A total of 60 patients will be randomized into 2 treatment groups in a 1:1 ratio (ticagrelor to 
clopidogrel).  Permuted block randomization will be used to allocate patients to treatment 
groups.  Fixed block sizes will be used to allocate treatment groups, thereby ensuring that sample 
size in each group is similar as the study progresses.  Blocked randomization lists will be 
computer generated and blinded to the investigators.  The investigator will not know the assigned 
treatment for a patient until the patient is randomization.  Patients will not be blinded to their 
treatment group. 
 
4.3 
Study Withdrawal 
 
Patients are free to withdraw their participation at any time during this clinical study.  The 
investigator also has the right to discontinue treatment with study drug if a serious adverse 
reaction to the study drug occurs.  Patients will be encouraged to remain in the study even if 
study drug is discontinued.  Reasons for early withdrawal of any patient from the study will be 
documented in the medical records.  If the reason for discontinuation of the study drug is from an 
adverse event it will be documented in the medical records and the case report forms. 
 
4.4 
Study Discontinuation 
 
The sponsor has the right to terminate the study at any time based on a recommendation 
from the Medical Monitor. 
 
5 
Treatment of Patients 
 
5.1 
Treatment Regimen 
 
Patients are placed on clopidogrel after their arterial intervention per SOC.  They will 
remain on clopidogrel up to the time that randomization occurs.  For patients that are randomized 
to ticagrelor, the clopidogrel will be stopped. 
 
 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
17 
 
 
 
Study Drug 
Dose Level and Frequency 
clopidogrel 
75 mg by mouth daily 
ticagrelor 
90 mg by mouth twice daily 
 
5.2 
Description of Study Drug 
 
Clopidogrel (Plavix®) is an FDA approved P2Y12 platelet inhibitor indicated for use in 
patients with acute coronary syndrome, recent MI, recent stroke, or established peripheral arterial 
disease.  See Appendix A for a complete description of the drug. 
Ticagrelor (Brilinta®) is an FDA approved P2Y12 platelet inhibitor indicated to reduce the 
rate of thrombotic cardiovascular events in patients with acute coronary syndrome (ACS) 
(unstable angina, non-ST elevation myocardial infarction, or ST elevation myocardial 
infarction).  See the Investigator Brochure for a complete description of the drug. 
 
5.3 
Obtaining Study Drugs 
 
Study medication (ticagrelor) will be provided for the patients from randomization until the 
time of the 6 month visit. 
 
5.4 
Concomitant Medications 
 
Patients should receive aspirin 81 mg by mouth every day as per labeling recommendations 
for ticagrelor and clopidogrel. 
 
5.5 
Prohibited Medications 
 
Treatment with the following medications are excluded during this study: 
 Aspirin doses greater than 100 mg per day 
 Oral anticoagulation with a vitamin K antagonist 
 Factor Xa inhibitors 
 Direct thrombin inhibitors 
 
6 
Study Procedures 
 
6.1 
Screening/Baseline 
 
The following procedures will be performed on all patients at screening: 
 
 Informed consent 
 Demographics (see section 6.4.1) 
 Medical History (see section 6.4.1) 
 Rutherford Classification (see Appendix B) 
 ABI, TBI, TSP 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
18 
 
 
 
 Measurement of wound size if Rutherford Classification Stage V or VI 
 Vital signs (B/P, HR, temperature, respirations) 
 The results of the following will be recorded from local laboratory tests that were 
performed in the month prior to screening:  BUN, crt, Hgb, Hct, plt, INR, PTT, 
HbA1c, Tchol, tg, LDL and HDL. 
 Urine pregnancy test for females of childbearing potential 
 Recent angiographic data 
 TcPO2 measurement (see section 6.4.2) 
 SPP measurement 
 Concomitant medications 
 Randomization 
 Dispense study drug 
 
6.2 
Month 3 follow up 
 
The patient will return to the clinic 3 months (90 days) after the date of randomization (+/- 2 
weeks) and the following procedures will be performed: 
 Rutherford Classification (see Appendix B) 
 ABI, TBI, TSP 
 Measurement of wound size and assessment of healing if Rutherford Classification 
Stage V or VI at Baseline 
 Vital signs (B/P, HR, temperature, respirations) 
 TcPO2 measurement (see section 6.4.2) 
 SPP measurement 
 Concomitant medications 
 Dispense study drug 
 Assess study medication compliance 
 Collect SAEs and AEs 
 
6.3 
Month 6 follow up 
 
The patient will return to the clinic 6 months (180 days) after the date of randomization (+/- 2 
weeks) and the following procedures will be performed: 
 Rutherford Classification (see Appendix B) 
 ABI, TBI, TSP 
 Measurement of wound size and assessment of healing if Rutherford Classification 
Stage V or VI at Baseline 
 Vital signs (B/P, HR, temperature, respirations) 
 TcPO2 measurement 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
19 
 
 
 
 SPP measurement 
 Concomitant medications 
 Assess study medication compliance 
 Collect SAEs and AEs 
 
Once a patient has been assessed at the 6-month follow-up visit they will exit the study.  If 
ongoing use of ADP-receptor antagonist is required, patients will continue with either 
medication as indicated and approved although it will not be provided as part of the study.   If no 
other indication exists for an ADP-receptor antagonist, either ticagrelor or clopidogrel will be 
discontinued, as per routine clinical practice.  
 
6.4 
Study Procedures 
The following procedures will be considered as study procedures: 
 
 TcPO2 measurement 
 SPP measurement 
 
Other procedures (Rutherford Classification, ABI, TBI, TSP, assessment of wound size and 
healing, vital signs, labs and angiographic procedures) are considered as SOC clinical 
procedures.  
6.4.1 Demographics and Medical History 
Demographic and medical history information to be collected include: age, race, gender, 
body-mass index, wound size, wound location, medical comorbidities including tobacco use 
history, duration of claudication, duration of lower extremity wound (if applicable), 
hypertension, hyperlipidemia, diabetes mellitus, prior cerebrovascular accident (CVA) or 
transient ischemic attack (TIA), carotid artery stenosis > 50%, chronic kidney disease (CKD), 
and complications related to prior PAD, such as prior wounds, forefoot amputation, below knee 
amputation, above knee amputation.  Angiographic data relevant to revascularization procedures, 
including a record of arterial segment treated and vascular anatomy, will also be recorded.   
 
6.4.2 Measurement of TcPO2 
 
Assessment of TcPO2 will be performed using the Perimed Periflux System 5000 
(Perimed Inc., Ardmore, PA) equipped with laser Doppler and transcutaneous oximetry function 
units.  Before each measurement, the device will be calibrated as per manufacturer’s 
specifications.  Patients will be asked to refrain from tobacco use or caffeine 12 hours prior to 
TcPO2 assessment.  All measurements will be performed in the supine position.  A site distant 
from the diseased area (right subclavicular region) will be used as a reference value (12, 18). 
Skin perfusion is strongly dependent upon skin temperature.  Accurate and reproducible 
assessment of tissue oxygenation requires measurement at maximal hyperemia.  Measurement at 
peak blood flow provides consistency of measurements at peak cutaneous blood flow reserve.   
Therefore, assessment of TcPO2 requires local tissue warming around the cutaneous ulcer site to 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
20 
 
 
 
a prespecified temperature.  As part of the Perimed system, the PF 5020 Temp Unit will be used 
to gradually warm the perimeter of the wound at sites of measurement to a steady state of 44°C 
(43-45°C) as per manufacturer specifications.   
In patients with Stage IV (no wound) the level of the great toe will be used as the site for 
measurement of TcPO2.  In the event of previous amputations, the most distal aspect of the foot 
will be used for the measurement.  In order to ensure that subsequent assessments are consistent 
with the index measurement, the area used will be documented in the records 
From room temperature (30-34°C), thermal steady state is achieved in 3-5 minutes and is 
maintained during tissue assessment.  All subsequent TcPO2 assessments will be made at 44°C 
(43-45°C) to ensure maximal hyperemia and measurement accuracy.  After the site of TcPO2 
adhesion is prepared, the instrument is calibrated at thermal steady state (3-5 minutes).  
Continuous TcPO2 monitoring then commences over 10-15 minutes until transcutaneous oxygen 
pressure also reaches steady state.   
Follow-up TcPO2 measurements (Perimed © Periflux System 5000) will be performed at 
3 and 6 months after revascularization for the purposes of this study.  Repeated measures for this 
study at 3 and 6 months are necessary to assess the interval change of TcPO2 and to provide 
additional accuracy of statistical modeling of secondary efficacy endpoints. 
6.4.3 Measurement of Skin Perfusion Pressure 
 
The skin perfusion pressure (SPP) is used to measure blood in the microcirculation 
around and within a wound using photoplethysmography with Doppler techniques and can be a 
useful predictor of wound healing potential.  The SPP is performed by applying a pressure cuff 
to the extremity with the wound.  Using a Doppler the measurement of the pressure at which 
perfusion first returns to the cutaneous microcirculation is obtained.  
6.4.4 Ankle-Brachial Index 
 
The ankle-brachial index (ABI) is a measurement that is the standard of care in the 
diagnosis of lower extremity PAD.  The ABI also provides an objective baseline assessment that 
can be used to follow the progression of the disease process and evaluate the effectiveness of the 
disease plan.  The ABI is performed by measuring the systolic blood pressure using a Doppler 
instrument from both brachial arteries and from both the dorsalis pedis and posterior tibial 
arteries after the patient has been at rest in the supine position for 10 minutes (23). 
ABI measurement will be obtained at baseline, month 3 and month 6.   
6.4.5 Toe-Brachial Index and Toe-Systolic Pressure 
 
The toe-brachial index (TBI) and toe-systolic pressure are a more reliable indicator of 
limb perfusion in patients with diabetes or the elderly because the small vessels of the toes are 
often spared from the medial calcification that may occur in the leg arteries.  A small occlusive 
cuff is placed on the proximal portion of the great toe (or another toe in the event of an 
amputation).  A photo-electrode is placed on the end of the toe to obtain an arterial waveform 
using infrared light.  The return of toe pulsality is assessed by use of a plethysmographic 
detection device.  The systolic pressure (TSP) is recorded at the point in which the baseline 
waveform is re-established.  The ratio of the recorded toe systolic pressure (TSP) to the higher of 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
21 
 
 
 
the two brachial pressures gives the TBI (23).  TBI and TSP measurements will be obtained at 
baseline, month 3 and month 6.   
 
7 
Pharmacologic Loading Pre-revascularization 
For patients requiring revascularization, pharmacologic loading of an ADP-receptor 
antagonist will have been ordered as per standard of care so as to minimize risks for post-
procedural arterial thrombosis.  For this study, patients will have been treated with clopidogrel 
up to, during, and immediately after the time of revascularization as is standard of care. After 
revascularization, an ADP-receptor antagonist (e.g., clopidogrel) is routinely continued for 6 
months, and then discontinued.  Patients will be screened and randomized for the study either in 
the hospital after the procedure prior to discharge or at the time of the first out-patient clinic visit 
following revascularization (approximately one to two weeks after the procedure).  Patients will 
be randomized to either clopidogrel or ticagrelor.  After randomization patients will receive 
study medication (ticagrelor) with a 90-day provision through 6 months follow-up, refilled at the 
3 month clinic visit.   
 
8 
Safety Monitoring and Reporting 
An adverse event is the development of an undesirable medical condition or the 
deterioration of a pre-existing medical condition following or during exposure to a 
pharmaceutical product, whether or not considered causally related to the product.   
The term AE is used to include both serious and non-serious AEs. 
 
An important medical event is any AE that may not result in death, be life-threatening, or require 
hospitalization but may be considered an SAE when, based upon appropriate medical judgment, 
it may jeopardize the patient and may require medical or surgical intervention to prevent one of 
the outcomes listed in the definitions of SAEs. 
 
8.1 
Adverse Events 
The following adverse events will be collected from the time that informed consent is 
obtained for this study:  
 Self-reported shortness of breath  
 Symptomatic bradycardia defined as self-reported symptoms of shortness of breath, chest 
discomfort, or dizziness with a confirmed heart rate of < 45 bpm at the time of the 
symptoms. 
 Adverse events that are not listed in the current labeling for the drugs (see Appendix A 
and Investigator Brochure for ticagrelor). 
 Events that lead to discontinuation of drug or result in a dose modification. 
 
8.2 
Serious Adverse Events 
The following SAEs will be collected from the time that informed consent is obtained until 
the month 6 visit: 
 
 Death. 
 Life threatening AEs. 
 Requires inpatient hospitalization or prolongation of existing hospitalization. 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
22 
 
 
 
 A disability/incapacity. 
 A congenital anomaly/birth defect in the offspring of a patient who received drug. 
 Important medical event that may jeopardize the subject or may require medical 
intervention to prevent one of the outcomes listed above. 
 Medical or scientific judgment should be exercised in deciding whether 
expedited reporting is appropriate in this situation.  Examples of medically 
important events are intensive treatment in an emergency room or at home 
for allergic bronchospasm, blood dyscrasias, or convulsions that do not 
result in hospitalizations; or development of drug dependency or drug 
abuse. 
 
8.3 
Other Events of Special Interest Considered as Serious 
 Major bleeding defined as a composite of fatal bleeding, intracranial bleeding, 
hypovolemic shock or severe hypotension due to bleeding requiring pressors, or 
need for transfusion of at least 2 units in any 24-hour period.   
 Major adverse limb events (surgical limb loss, major repeat revascularizations 
including thrombectomy, thrombolysis, or major lower extremity surgical 
procedure. 
 
8.4 
Documentation and Reporting of Adverse Events 
Prompt reporting of the SAE to the Sponsor is essential so that legal and ethical 
obligations can be fulfilled.  SAEs will be reported to the Sponsor within 24 hours of learning of 
the event.  The causality of the SAE (the relationship to the study treatment/procedures) will be 
assessed by the investigator and reported to the Sponsor.  The SAE will also be documented on 
the appropriate eCRF.  
 
Since the Critical Limb Ischemia Study is exempted from IND reporting, the Sponsor 
does not have the responsibility to report any AEs/SAEs to the FDA.  The Investigator will 
report all SAEs (regardless of causality or expectedness) and cases of pregnancy and overdose to 
the Sponsor and the Sponsor will report these events to AstraZeneca, so they can fulfill the 
regulatory reporting requirement.   
 
The SAE awareness date will be the date that the investigator determines that the event 
meets protocol-specific criteria for an SAE.  The SAE will be reported to AstraZeneca by the 
Sponsor within 24 hours of awareness. 
 
The investigator is responsible for informing the IRB of the SAE as per local 
requirements. 
 
The Sponsor will send the SAE report that will contain the MedWatch form and 
accompanying cover page by way of email to AstraZeneca’s designated mailbox: 
AEMailboxClinicalTrialTCS@astrazeneca.com.  The cover page will include the following: 
 Investigator sponsored study (ISS) 
 The Investigator’s name and address 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
23 
 
 
 
 The study name/title and AstraZeneca ISS reference number 
 The causality of the SAE as reported by the Investigator. 
 
If a non-serious AE becomes serious, this and other relevant follow-up information must 
also be provided to AstraZeneca. 
 
8.5 
Safety Monitoring 
Safety endpoints to be assessed include major bleeding and self-reported dyspnea and self-
reported symptomatic bradycardia.  Major bleeding is defined as a composite of fatal bleeding, 
intracranial bleeding, hypovolemic shock or severe hypotension due to bleeding requiring 
pressors, or need for transfusion of at least 2 units in any 24-hour period.  Self-reported 
symptomatic bradycardia is defined as self-reported symptoms of shortness of breath, chest 
discomfort, or dizziness with a confirmed heart rate of < 45 bpm at the time of the symptoms. 
 
9 
Statistical Plan 
 
9.1 
Statistical Methods 
Baseline covariates will be compared with Fisher’s exact test for categorical variables and 
two-sample t-test for continuous variables with a normal distribution or rank sum test if non-
normally distributed between treatment groups.  All comparisons between treatment groups will 
be performed as intent-to-treat using two-tailed significance testing at a value of 0.05.   
Mixed model repeated measures analysis (MMRM) will be used to conduct the between-group 
comparison of absolute change in TcPO2 at 3 months and 6 months follow-up, with adjustment 
of baseline TcPO2 level following revascularization. Estimated within-group least squares (LS) 
means of TcPO2 and between-group differences of LS means in TcPO2 at 3- and at 6-month 
follow-up time points will be obtained from the MMRM modeling.   
If the TcPO2 data is not normally distributed, the same MMRM method will be performed to 
analyze the rank transformed TcPO2 data, however the descriptive data is presented with median 
(interquartile range), and the between-group differences are shown using F statistics. Meanwhile, 
relevant nonparametric methods will be applied as sensitivity analysis. Friedman test will be 
conducted to compare the TcPO2 repeated measures from baseline to 6 months follow-up 
between the treatment groups. A Wilcoxon signed rank test will be used to assess intragroup 
change in TcPO2 at 3- and at 6-month follow-up.    
The percent change in TcPO2 over time and other continuous secondary endpoints will be 
analyzed using the same strategies. Safety endpoints, adverse events and other categorical 
secondary endpoints will be analyzed using Fisher’s exact test. The relationships between the 
primary endpoint of change in TcPO2 at 6 months follow-up and the continuous secondary 
endpoints will be explored by regression analysis. 
 
9.2 
Sample size  
The goal of this study is to compare the absolute change in TcPO2 among recently 
revascularized patients randomized to intervention (ticagrelor) or control (clopidogrel).  With 60 
patients, 30 per treatment group, this study will have 90% power at an acceptably low type I 
error rate (0.05) to detect a clinically significant 8 ± 8 mmHg difference in TcPO2, as discussed 
below. 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
24 
 
 
 
It is anticipated that most revascularized patients will have a baseline TcPO2 result of 
approximately 40 mmHg, whereby a 25% change would reflect a final TcPO2 result of 50 
mmHg.  The standard deviation (SD) for TcPO2 among such a population is estimated to be 16 
mmHg based on previously published data (11,19,20).  The actual change in TcPO2 that might 
be induced by either ticagrelor or clopidogrel is unknown.  However, based on our hypothesis of 
improved tissue oxygen tension with ticagrelor, it is anticipated that the ticagrelor group will 
increase TcPO2 to a greater degree with a SD for the intergroup difference approximately 50% 
of the baseline SD (16 mmHg).  Therefore, we have designed this study to detect an intergroup 
difference in TcPO2 of 8 ± 8 mmHg assessed at 6 months.   Even if clopidogrel induces no 
change in TcPO2 from baseline, an 8 mmHg increase in the ticagrelor group would represent a 
20% improvement over baseline.   
Given these assumptions, 26 patients per group will provide sufficient power to detect a large 
effect size that also reflects a clinically significant change in TcPO2 values.  Adjusting for non-
adherence and allowing for a 5% rate of crossover from ticagrelor to controls would require 28 
patients per group.  Attrition rates for this study are anticipated to be low and likely < 5%.  
However, given the severity of underlying illness among a population of severely symptomatic 
PAD, including previously reported mortality rates of 25% at 2 years (21), it seems reasonable to 
assume our population will have a baseline annual mortality rate of 5-10%.  Adjusting the study 
with 30 patients per group would allow for 7.5% attrition while maintaining power to determine 
the desired effect.    
Finally, our analysis will use 3 repeated measures to assess the TcPO2 endpoint at baseline, 3 
months, and 6 months. The Friedman repeated measures ANOVA on ranks will be used to 
calculate the main effect differences among measurements repeated over time.  This technique is 
particularly suitable if a great deal of variation between samples, especially at low TcPO2, where 
error variance estimates from standard ANOVA may be large. 
 
 
10 Study Committees 
 
The following committees will be responsible for the management of the study and the 
monitoring of the safety of the study patients. 
 
10.1 Executive Steering Committee 
 
The Executive Steering Committee (ESC) will have scientific responsibility for the study.  They 
will review study conduct and progress, consider recommendations from the Medical Monitor 
and resolve any other study related issues. 
 
10.2 Safety Monitoring Board 
 
An independent Medical Monitor will be appointed to monitor the study by reviewing the case 
report forms, SAE and AE forms at specified intervals throughout the study and will be 
responsible for the oversight of safety. 
 
11 Data Handling and Record Keeping 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
25 
 
 
 
11.1 Data Collection 
 
Data will be collected by the Nurse or Site Coordinator or designee.  Data sources include patient 
reports and available medical records, including those from electronic medical record.  Values 
for preoperative variables will be selected nearest to the date of the revascularization procedure, 
but used only if they were obtained within 30 days of the procedure. 
C5Research Data Management will create a Case Report Form to document the agreed upon 
variables to be captured in the REDCap database.  
 
11.2 REDCap Database:  
 
Study data will be collected and managed by the site using REDCap (Research Electronic Data 
Capture).  REDCap is a secure, web application designed to support data capture for research 
studies, providing user-friendly web-based case report forms, real-time data entry validation (e.g. 
for data types and range checks), audit trails and a de-identified data export mechanism to 
common statistical packages (SPSS, SAS, Stata, R/S-Plus).  The system was developed by a 
multi-institutional consortium which includes Cleveland Clinic and was initiated at Vanderbilt 
University.  The database is hosted at the Cleveland Clinic Datacenter.  The system is protected 
behind a login and Secure Sockets Layer (SSL) encryption.  There is an audit trail tracking all 
logins and activities in the database.  Data collection is customized for each study or clinical 
study based on a study-specific data dictionary defined by the research team with guidance from 
the REDCap administrator in Quantitative Health Sciences at the Cleveland Clinic. 
 
11.3 REDCap Completion Guidelines:  
 
Cleveland Clinic Data Management (DM) will create a REDCap Completion Guidelines 
document to assist the site in data entry.   
 
11.4 Retention of Records 
 
Investigator files containing study related documents will be retained according to the agreed 
timeframe outlined in the contractual agreement and at least for a minimum of two (2) years after 
a marketing application is approved for the drug; or 2 years after investigational use is 
discontinued and FDA has been notified in accordance with the applicable regulations.   
Records shall be accessible for inspection by authorized representatives of the Sponsor, or the 
FDA.  Records may be discarded upon written notification by the Sponsor. To avoid error, the 
Principal Investigator should contact C5Research / AstraZeneca, before the destruction of any 
records and reports pertaining to the study to ensure they no longer need to be retained. In 
addition, the Sponsor should be contacted if the Principal Investigator plans to leave the 
investigational site so that appropriate arrangements for file custodianship can be made. 
 
 
12 Study Monitoring, Auditing, and Inspecting 
C5Research is responsible for monitoring the safety and effectiveness of this study. 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
26 
 
 
 
The study will be monitored according to the Monitoring Plan, per the applicable C5Research 
Standard Operating Procedures for clinical monitoring and in compliance with Title 21 CFR Part 
312. 
 
13 Ethical Considerations 
 
This study will be performed in accordance with the protocol, International Conference on 
Harmonization Good Clinical Practice guidelines and the Cleveland Clinic IRB. 
The Investigator has the ethical and legal responsibility to ensure that each patient is given a full 
explanation of the study.  Written informed consent will be obtained from all patients before any 
study-specific procedures are performed. 
The Cleveland Clinic IRB must review and approve the protocol and informed consent form 
before the study can begin. 
 
14 Publication  
 
The study investigators will present and publish the results of the study.   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
27 
 
 
 
 
 
 
 
 
15 References 
 
1. 
Falanga V. Wound healing and its impairment in the diabetic foot. Lancet 
2005;366:1736-43. 
2. 
Montesinos MC, Desai A, Chen JF et al. Adenosine promotes wound healing and 
mediates angiogenesis in response to tissue injury via occupancy of A(2A) receptors. The 
American journal of pathology 2002;160:2009-18. 
3. 
Feoktistov I, Biaggioni I, Cronstein BN. Adenosine receptors in wound healing, fibrosis 
and angiogenesis. Handbook of experimental pharmacology 2009:383-97. 
4. 
Serebruany VL. Adenosine release: a potential explanation for the benefits of ticagrelor 
in the PLATelet inhibition and clinical outcomes trial? American heart journal 2011;161:1-4. 
5. 
Grzesk G, Kozinski M, Navarese EP et al. Ticagrelor, but not clopidogrel and prasugrel, 
prevents ADP-induced vascular smooth muscle cell contraction: A placebo-controlled study in 
rats. Thrombosis research 2012. 
6. 
Pasqualini L, Pirro M, Lombardini R, Ciuffetti G, Dragani P, Mannarino E. A human 
model of platelet-leucocyte adhesive interactions during controlled ischaemia in patients with 
peripheral vascular disease. Journal of clinical pathology 2002;55:946-50. 
7. 
Mahaffey KW, Puma JA, Barbagelata NA et al. Adenosine as an adjunct to thrombolytic 
therapy for acute myocardial infarction: results of a multicenter, randomized, placebo-controlled 
trial: the Acute Myocardial Infarction STudy of ADenosine (AMISTAD) trial. Journal of the 
American College of Cardiology 1999;34:1711-20. 
8. 
Ross AM, Gibbons RJ, Stone GW, Kloner RA, Alexander RW. A randomized, double-
blinded, placebo-controlled multicenter trial of adenosine as an adjunct to reperfusion in the 
treatment of acute myocardial infarction (AMISTAD-II). Journal of the American College of 
Cardiology 2005;45:1775-80. 
9. 
Quintana M, Hjemdahl P, Sollevi A et al. Left ventricular function and cardiovascular 
events following adjuvant therapy with adenosine in acute myocardial infarction treated with 
thrombolysis, results of the ATTenuation by Adenosine of Cardiac Complications (ATTACC) 
study. European journal of clinical pharmacology 2003;59:1-9. 
10. 
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG. Inter-Society 
Consensus for the Management of Peripheral Arterial Disease (TASC II). Journal of vascular 
surgery : official publication, the Society for Vascular Surgery [and] International Society for 
Cardiovascular Surgery, North American Chapter 2007;45 Suppl S:S5-67. 
11. 
Yamada T, Ohta T, Ishibashi H et al. Clinical reliability and utility of skin perfusion 
pressure measurement in ischemic limbs--comparison with other noninvasive diagnostic 
methods. Journal of vascular surgery : official publication, the Society for Vascular Surgery 
[and] International Society for Cardiovascular Surgery, North American Chapter 2008;47:318-
23. 
12. 
Kalani M, Brismar K, Fagrell B, Ostergren J, Jorneskog G. Transcutaneous oxygen 
tension and toe blood pressure as predictors for outcome of diabetic foot ulcers. Diabetes care 
1999;22:147-51. 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
28 
 
 
 
13. 
Wallentin L, Becker RC, Budaj A et al. Ticagrelor versus clopidogrel in patients with 
acute coronary syndromes. The New England journal of medicine 2009;361:1045-57. 
14. 
Tepe G, Bantleon R, Brechtel K et al. Management of peripheral arterial interventions 
with mono or dual antiplatelet therapy-the MIRROR study: a randomised and double-blinded 
clinical trial. European radiology 2012. 
15. 
Schleinitz MD, Weiss JP, Owens DK. Clopidogrel versus aspirin for secondary 
prophylaxis of vascular events: a cost-effectiveness analysis. The American journal of medicine 
2004;116:797-806. 
16. 
Jones L, Griffin S, Palmer S et al. Clinical effectiveness and cost-effectiveness of 
clopidogrel and modified-release dipyridamole in the secondary prevention of occlusive vascular 
events: a systematic review and economic evaluation. Health Technol Assess 2004;8:iii-iv, 1-
196. 
17. 
Hirsch AT, Haskal ZJ, Hertzer NR et al. ACC/AHA 2005 guidelines for the management 
of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal 
aortic): executive summary a collaborative report from the American Association for Vascular 
Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and 
Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, 
and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop 
Guidelines for the Management of Patients With Peripheral Arterial Disease) endorsed by the 
American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, 
and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and 
Vascular Disease Foundation. Journal of the American College of Cardiology 2006;47:1239-312. 
18. 
Quigley FG, Faris IB. Transcutaneous oxygen tension measurements in the assessment of 
limb ischaemia. Clin Physiol 1991;11:315-20. 
19. 
Wagener JS, Hendricker C. Intra-subject variability of noninvasive oxygen 
measurements. Chest 1987;92:1047-9. 
20. 
Kragelj R, Jarm T, Miklavcic D. Reproducibility of parameters of postocclusive reactive 
hyperemia measured by near infrared spectroscopy and transcutaneous oximetry. Annals of 
biomedical engineering 2000;28:168-73. 
21. 
Criqui MH, Langer RD, Fronek A et al. Mortality over a period of 10 years in patients 
with peripheral arterial disease. The New England journal of medicine 1992;326:381-6. 
22. 
Roger VL, Go AS, Lloyd-Jones DM et al. Heart disease and stroke statistics--2012 
update: a report from the American Heart Association. Circulation 2012;125:e2-e220. 
23.       Hirsch AT, Haskal ZJ, Hertzer NR, et al.  ACC/AHA 2005 Practice Guidelines for the 
management of patients with peripheral arterial disease; e491-e497. 
 
 
 
 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
29 
 
 
 
Appendix A 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
30 
 
 
 
 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
31 
 
 
 
 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
32 
 
 
 
 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
33 
 
 
 
 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
34 
 
 
 
 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
35 
 
 
 
 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
36 
 
 
 
 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
37 
 
 
 
 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
38 
 
 
 
 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
39 
 
 
 
 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
40 
 
 
 
 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
41 
 
 
 
 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
42 
 
 
 
 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
43 
 
 
 
 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
44 
 
 
 
 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
45 
 
 
 
 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
46 
 
 
 
 
 
 


Confidential 
               Amendment #3_V 4.0_21Sep2017  
 
Page 
47 
 
 
 
 
 


 
Confidential 
Page 48                       Protocol v 0.4-02Apr2014 
 
 
Appendix B 
 
Rutherford Classification 
 
 
     ●Stage 0 – Asymptomatic 
 
     ●Stage 1 – Mild claudication 
 
     ●Stage 2 – Moderate claudication  
 
     ●Stage 3 – Severe claudication 
 
     ●Stage 4 – Rest pain 
 
     ●Stage 5 – Ischemic ulceration not exceeding ulcer of the digits of the foot 
 
     ●Stage 6 – Severe ischemic ulcers or frank gangrene