Analysis of Low-Dose Rivaroxaban Following Peripheral Vascular Intervention in the Post-Voyager Era: Prescription Patterns, Predictors, Outcomes, and Vascular Surgeons’ Insights

Document Type

Conference Proceeding

Publication Date

7-1-2026

Publication Title

J Vasc Surg

Keywords

anticoagulant agent, antithrombocytic agent, rivaroxaban, adult, amputation, amputation free survival, anticoagulation, conference abstract, controlled study, drug combination, dual antiplatelet therapy, equipoise, female, follow up, human, low drug dose, low socioeconomic status, major clinical study, male, peripheral arterial disease, prescribing practice, randomized controlled trial, special situation for pharmacovigilance, surgery, vascular surgeon, vascularization

Abstract

Objectives: Contemporary guidelines endorse dual pathway inhibition (DPI) with low-dose rivaroxaban plus antiplatelet therapy in patients with peripheral artery disease undergoing lower extremity peripheral vascular intervention (PVI). However, national adoption patterns and real-world outcomes of DPI after PVI remain poorly characterized. Methods: Patient with peripheral artery disease undergoing PVI between January 2024 and December 2025 were identified in the Vascular Quality Initiative. Patients on preoperative or postoperative full-dose anticoagulation were excluded. Discharge antithrombotic regimens were categorized as single antiplatelet therapy (SAPT), dual antiplatelet therapy (DAPT), or DPI defined as a single antiplatelet agent combined with low-dose rivaroxaban (2.5 mg twice daily). Multivariable logistic regression was used to identify factors independently associated with DPI initiation. Cox regression was used to evaluate the long-term outcomes of reintervention and amputation-free survival. In parallel, an anonymous survey was distributed to a statewide vascular surgery society to assess perceptions regarding the clinical benefit of DPI. Results: Among 60,601 patients undergoing PVI during the study period, 21% were discharged on SAPT, 72% on DAPT, and 7% on DPI. DPI utilization varied substantially across geographical regions (range, 4%-17%) and individual centers (range, 0%-51%). Significant predictors of DPI initiation included prior lower extremity revascularization (odds ratio [OR], 2.55; 95% confidence interval [CI], 2.37-2.73; P < .001), multivessel treatment (OR, 1.43; 95% CI, 1.21-1.70; P < .001), infrapopliteal intervention (OR, 1.28; 95% CI, 1.15-1.42; P < .001), TASC C/D lesions (OR, 1.59; 95% CI, 1.36-1.87; P < .001), and in-hospital target vessel thrombosis (OR, 3.20; 95% CI, 2.28-4.48; P < .001) (Fig 1). In contrast, lower socioeconomic status was associated with a 20% reduction in the odds of DPI initiation (OR, 0.81; 95% CI, 0.73-0.90; P < .001). At the 18-month follow-up, no difference in reintervention (hazard ratio [HR], 1.33; 95% CI, 0.98-1.80; P = .066), amputation (HR, 1.22; 95% CI, 0.75-1.98; P = .424), or amputation-free survival (HR, 1.15; 95% CI, 0.94-1.41; P = .170) was observed with DPI compared to SAPT or DAPT (Fig 2). Eighty percent of vascular surgeons reported uncertainty regarding the clinical benefit of DPI, with the majority (88%) expressing interest in a randomized controlled trial comparing DAPT with DPI and 92% indicating willingness to enroll patients in such trial. Conclusions: Although endorsed by contemporary guidelines, DPI after PVI is infrequently and variably used, primarily in patients with advanced disease complexity. In this national cohort, DPI was not associated with a measurable reduction in amputation or reintervention. Persistent surgeon uncertainty and broad willingness to enroll patients in a randomized trial suggest that current practice may reflect true clinical equipoise rather than simple failure to adopt guideline recommendations. [Formula presented] [Formula presented]

Volume

84

Issue

1

First Page

e58

Last Page

e59

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