Beyond DAPT for PAD: Dual Antithrombotic Pathway Inhibition Reduces Limb Events and Proves Cost-effective

Document Type

Conference Proceeding

Publication Date

10-1-2025

Publication Title

J Vasc Surg

Abstract

Introduction and Objectives: Antithrombotic therapy is essential for medical management of patients with peripheral arterial disease to prevent major adverse limb events and major adverse cardiovascular events. Although dual antiplatelet therapy (DAPT = aspirin + clopidogrel) has been widely studied, emerging evidence suggests that combining factor Xa inhibitors with clopidogrel may offer additional mitigation as it provides dual antithrombotic pathway inhibition (DAPI). This study aims to evaluate the outcomes and the cost-effectiveness of patients treated with DAPI compared with DAPT after lower extremity revascularization (LER). Methods: A retrospective review of patients who underwent open and endovascular LER in a tertiary center was performed. The characteristics of patients treated with DAPT and DAPI were compared after propensity matching (4:1). Cost-effectiveness was assessed using cost ($) and quality-adjusted life year (QALY) modeled for 5 years after LER. The incremental cost-effectiveness ratio (cost per QALY gained) was derived with a willingness-to-pay threshold of $150,000 per QALY. Results: A total of 987 patients underwent LER, most discharged on DAPT (95.5%) and only 5.6% (N = 55) on DAPI. Patients discharged on DAPI were significantly older (80 vs 72, P < .001), more likely to have congestive heart failure (27% vs 13%, P = .003), and more likely to be treated for chronic limb-threatening ischemia (62% vs 44%, P = .011). After matching, the Kaplan-Meier analysis demonstrated that patients treated with DAPI had significantly higher major adverse limb event-free survival, but there was no difference in major adverse cardiovascular event-free survival (Fig 1). DAPI was more expensive ($73,826 vs $39,548) but provided additional QALYs (4.64 vs 3.51) and was cost-effective with an incremental cost-effectiveness ratio of $30,331 per QALY compared with DAPT (decision tree in Fig 2). Conclusions: DAPI after LER is used in a relatively older patient cohort with increased comorbidities. In this patient population, DAPI seems to be associated with better outcomes than DAPT and is a cost-effective strategy for antithrombotic therapy. [Formula presented] [Formula presented]

Volume

82

Issue

4

First Page

e103

Last Page

e104

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