The Incidence and Significance of Delayed Bleeding Events After Lower Extremity Revascularization in Patients with Advanced Peripheral Arterial Disease.

Abstract

Objectives: As novel medications are used in various combinations to prevent thrombosis, few studies have focused on bleeding events after lower extremity revascularization (LER) in patients with peripheral artery disease (PAD). Moreover, the impact of bleeding events on long-term outcomes and the prescription of antithrombotic therapy is not well reported. This study examines the incidence of bleeding events after LER and their significance in patients with advanced PAD.

Methods: A retrospective review of patients undergoing LER for PAD in a tertiary care center was performed. Bleeding was classified into major and minor based on the International Society of Thrombosis definitions and captured outside the 30-day perioperative period of LER. Characteristics and outcomes of patients who experienced bleeding events more than 30 days after initial LER were compared to patients who did not.

Results: A total of 1,932 patients underwent LER and 529 (27.4%) experienced a bleeding event (53% major, 47% minor) over 4.3 years. Patients who experienced a bleeding event were more likely to have hypertension (93% vs 89%, p = .005), coronary artery disease (58% vs 53% p = .047), chronic renal insufficiency (25% vs 16%, p < .001), end-stage renal disease (12% vs 6.8%, p < .001), a history of smoking (84% vs 79% p = .007), and be on dual antiplatelet therapy (DAPT) (31% vs 25%, p = 0.029) at baseline. Patients who experienced a bleeding event after 30 days were also more likely to have developed perioperative bleeding (7.6% vs 5.2% p = 0.049) after the first LER. On follow-up, patients with bleeding were more likely to have reinterventions (51% vs 43%, p = .002), major amputation (14% vs 7.1%, p < .001), myocardial infarction (33% vs 17%, p <0.001), stroke (9.5% vs 5.1%, p <0.001), and mortality (48% vs 38%, p < .001). The most common type of bleeding was gastrointestinal (47%) followed by surgical site unrelated to LER (13%), and intracranial. Blood transfusion was used in 48%. Moreover, 40% of patients with an initial bleeding episode had at least one recurrent bleeding episode with a mean of 2.9 bleeding episodes per patient. After the first bleeding episode, 15% of patients were discharged without any antithrombotic therapy and 13%, 16%, and 11% had discontinuation of ASA, P2Y12 inhibitors, and anticoagulation respectively.

Conclusion: Bleeding events are common after LER for advanced PAD and are associated with worse overall outcomes. Recurrent bleeding events are likely and significantly affect antithrombotic medication prescriptions.