VESS04 - The Incidence and Significance of Bleeding in Patients with Advanced Peripheral Arterial Disease

Objectives: Platelet inhibition is an essential component of medical therapy for peripheral arterial disease (PAD). As novel medications are used in various combinations to prevent thrombosis, very little research has focused on bleeding and its impact on the prescription of antithrombotic therapy (antiplatelets and anticoagulation). This study examines the incidence of long-term bleeding and its significance in patients with advanced PAD undergoing lower extremity revascularization (LER).

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 periods of LER. Characteristics and outcomes of patients who experienced delayed non-surgical bleeding events after initial LER were compared to patients who did not develop bleeding.

Results: A total of 1,932 patients underwent LER and 529 (27.4%) developed delayed bleeding (53% major, 47% minor) after a mean follow-up of 4.3 years. Patients who experienced bleeding 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), and a history of smoking (84% vs 79% p = .007) at baseline. Use of antithrombotics was similar between both groups at baseline. There was no significant difference in indication or type of initial LER (Table I). Patients who developed long-term bleeding were also more likely to develop perioperative bleeding (7.6% vs 5.2% p = 0.049) after the first LER. On follow-up, patients who experienced bleeding were more likely to have reinterventions (51% vs 43%, p = .002), major amputation (14% vs 7.1%, p < .001), and mortality (48% vs 38%, p < .001) (Table II). The most common type of bleeding was gastrointestinal (47%) followed by intracranial (9.8%) and genitourinary (9.0%). 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.

Conclusions: Bleeding is common in patients with advanced PAD and seems to be associated with worse overall outcomes. Bleeding events tend to recur in patients and significantly impact antithrombotic medication prescriptions.