This is the current release of the guideline.

This guideline updates a previous version: Jackson MR, Clagett GP. Antithrombotic therapy in peripheral arterial occlusive disease. Chest 2001 Jan;119(1 Suppl):283S-299S.

The rating scheme is defined at the end of the "Major Recommendations" field.

Chronic Limb Ischemia

Antiplatelet Therapy

Aspirin

1. The guideline developers recommend lifelong aspirin therapy, 75 to 325 mg/day, in comparison to no antiplatelet therapy in patients with clinically manifest coronary or cerebrovascular disease (Grade 1A) and in those without clinically manifest coronary or cerebrovascular disease (Grade 1C+)

Ticlopidine

1. The guideline developers recommend clopidogrel over ticlopidine (Grade 1C+).

Clopidogrel

1. The guideline developers recommend clopidogrel in comparison to no antiplatelet therapy (Grade 1C+), but suggest that aspirin be used instead of clopidogrel (Grade 2A).

   Underlying values and preferences: This recommendation places a relatively high value on avoiding large expenditures to achieve small reductions in vascular events.

Cilostazol

1. For patients with disabling intermittent claudication who do not respond to conservative measures (risk factor modification and exercise therapy) and who are not candidates for surgical or catheter-based intervention, the guideline developers suggest cilostazol (Grade 2A). The guideline developers suggest that clinicians not use cilostazol in those with less-disabling claudication (Grade 2A).

   Underlying values and preferences: The recommendation against cilostazol for those with less-disabling claudication places a relatively low value on small possible improvements in function in the absence of clear improvement in health-related quality of life.

Pentoxifylline

1. The guideline developer recommend against the use of pentoxifylline (Grade 1B).

Prostaglandins

1. For limb ischemia, the guideline developers suggest clinicians not use prostaglandins (Grade 2B).

   Underlying values and preferences: The recommendation places a low value on achieving small gains in walking distance in the absence of demonstrated improvement in quality of life.

Other Agents

1. In patients with intermittent claudication, the guideline developers recommend against the use of anticoagulants (Grade 1A).

Acute Limb Ischemia

Heparin

1. In patients with acute arterial emboli or thrombosis, the guideline developers recommend treatment with immediate systemic anticoagulation with unfractionated heparin (UFH) to prevent thrombotic propagation (Grade 1C). The guideline developers also recommend systemic anticoagulation with UFH followed by long-term vitamin K antagonist (VKA) to prevent recurrent embolism in patients undergoing embolectomy (Grade 1C).

Thrombolysis

1. In patients with short-term (<14 days) thrombotic or embolic disease with low risk of myonecrosis and ischemic nerve damage developing during the time to achieve revascularization by this method, the guideline developers suggest intra-arterial thrombolytic therapy (Grade 2B).

   Underlying values and preferences: This recommendation places relatively little value on small reductions in the need for surgical intervention and relatively high value on avoiding large expenditures and possible major hemorrhagic complications.

Vascular Grafts

Intraoperative Anticoagulation during Vascular Reconstruction

1. For patients undergoing major vascular reconstructive procedures, the guideline developers recommend UFH at the time of application of vascular cross-clamps (Grade 1A).

Prolonging the Patency of Grafts

Antiplatelet Agents

1. In patients undergoing prosthetic infrainguinal bypass, the guideline developers recommend aspirin (Grade 1A).

Vitamin K Antagonists (VKAs)

1. The guideline developers suggest that VKA not be used routinely in patients undergoing infrainguinal femoropopliteal or distal vein bypass (Grade 2A).

   Underlying values and preferences: This recommendation attributes relatively little value to small increases in long-term patency and relatively high value to avoiding hemorrhagic complications.

VKA Plus Aspirin

1. For routine patients undergoing infrainguinal bypass without special risk factors for occlusion, the guideline developers recommend against VKA plus aspirin (Grade 1A). For those at high risk of bypass occlusion and limb loss, the guideline developers suggest VKA plus aspirin (Grade 2B).

   Underlying values and preferences: These recommendations place high value on the avoidance of bleeding complications but recognize that there are circumstances where the threat of limb loss and major disability may supercede the risk.

Carotid Endarterectomy

Aspirin

1. The guideline developers recommend that aspirin, 75 to 325 mg/day, be given preoperatively and continued indefinitely in patients undergoing carotid endarterectomy (Grade 1A).

Asymptomatic and Recurrent Carotid Stenosis

1. In nonoperative patients with asymptomatic or recurrent carotid stenosis, the guideline developers recommend lifelong aspirin, 75 to 162 mg/day (Grade 1C+).

Lower Extremity Endovascular Procedures

1. For all patients undergoing lower-extremity balloon angioplasty (with or without stenting), the guideline developers recommend long-term aspirin, 75 to 162 mg/day (Grade 1C+).

Definitions

*These situations include RCTs with both lack of blinding and subjective outcomes, where the risk of bias in measurement of outcomes is high, or RCTs with large loss to follow-up.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Not applicable: The guideline was not adapted from another source.

2001 Jan (revised 2004 Sep)

American College of Chest Physicians - Medical Specialty Society

Funding was provided through an unrestricted educational grant by AstraZeneca LP, Aventis Pharmaceuticals, GlaxoSmithKline, Bristol-Myer Squibb/Sanofi-Synthelabo Partnership, and Organon Sanofi-Synthelabo LLC.

American College of Chest Physicians Consensus Panel on Antithrombotic and Thrombolytic Therapy

Primary Authors: G. Patrick Clagett, MD (Co-Chair); Michael Sobel, MD, Co-Chair; Mark R. Jackson, MD; Gregory Y. H. Lip, MD; Marco Tangelder, MD; Raymond Verhaeghe, MD

Committee Co-Chairs: Jack Hirsh, MD, FCCP (Chair); Gregory W. Albers, MD; Gordon H. Guyatt, MD, MSc; Holger J. Schünemann, MD, MSc, PhD, FCCP

Participants: Giancarlo Agnelli, MD; Amin Al-Ahmad, MD; Pierre Amarenco, MD; Jack E. Ansell, MD; Shannon M. Bates, MD; Richard C. Becker, MD; Peter B. Berger, MD; David Bergqvist, MD, PhD, FRCS; Rebecca J. Beyth, MD, MSc; Stewart Brower, MLIS; Harry R. Buller, MD; Henry I. Bussey, PharmD, FCCP; Christopher P. Cannon, MD, FACC; Elizabeth A. Chalmers, MB, ChB, MD, MRCP(UK). FRCPath; Anthony K.C. Chan, MD; G. Patrick Clagett, MD; Barry Coller, MD; Clifford W. Colwell, MD; Deborah Cook, MD, MSc; James E. Dalen, MD, MPH, FCCP; J. Donald Easton, MD; Michael Ezekowitz, MD; Garret A. Fitzgerald, MD; William H. Geerts, MD, FCCP; Jeffrey S. Ginsberg, MD, FCCP; Alan S. Go, MD; Shaun D. Goodman, MD, FACC; Ian A. Greer, MD, FRCP, FRCOG; Andreas Greinacher, MD; Jeremy Grimshaw, MD, PhD; Cindy Grines, MD; Jonathan L. Halperin, MD; Robert A. Harrington, MD; John Heffner, MD, MPH; John A. Heit, MD; Judith S. Hochman, MD, FACC; Dieter Horstkotte, MD, FESC; Russell D. Hull, MBBS, MSc, FCCP; Elaine Hylek, MD; Thomas M. Hyers, MD, FCCP; Mark R. Jackson, MD; Alan Jacobson, MD; Roman Jaeschke, MD, MSc; Ajay Kakkar BSc, PhD; Clive Kearon, MD, PhD, FCCP; Matthew Kraay; Michael R. Lassen, MD; Mark N. Levine, MD, MSc; Alessandro Liberati, MD; Gregory YH Lip, MD, FESC, FACC; Warren J. Manning, MD; M. Patricia Massicotte, MD, MSc, FRCPC, MSc; Thomas W. Meade, MD; Venu Menon, MD, FACC; Alan D. Michelson, MD; Nancy Miller, RN; Paul Monagle, MBBS, MSc, MD, FRACP, FRCPA, FCCP; Heather Munger, MLS; Christopher M. O’Connor, MD; Martin O’Donnell, MD; E. Magnus Ohman, MD, FCCP; Carlo Patrono, MD; Stephen G. Pauker, MD; Graham F. Pineo, MD; Leon Poller, MD; Jeffrey J. Popma, MD; Martin H. Prins, MD; Robert Raschke, MD, MS; Gary Raskob, PhD; Joel G. Ray, MD, MSc; Gerald Roth, MD; Ralph L. Sacco, MD; Deeb N. Salem, MD, FCCP; Meyer M. Samama, MD; Andrew Schafer; Sam Schulman, MD, PhD; Daniel Singer, MD; Michael Sobel, MD; Paul D. Stein, MD, FCCP; Marco Tangelder, MD; Victor F. Tapson, MD, FCCP; Philip Teal, MD; Raymond Verhaeghe, MD; David A. Vorchheimer, MD; Theodore E. Warkentin, MD; Jeffrey Weitz, MD; Robert G. Wilcox, MD

Dr. Sobel has received research funding from Commonwealth Biotechnologies Inc, and has received no honoraria or consulting fees from pharmaceutical or technology firms.

Dr. Jackson has not received industry funding for research and has not received honoraria during this time period.

Dr. Lip has received research funding from AstraZeneca, Merck, and Servier, and has received honoraria for his participation on advisory boards and/or as a speaker at educational events from AstraZeneca, Servier, Boehringer Ingelheim, Novartis, Mitsubishi, Pharma, Yamanuchi, Bristol-Myers Squibb, Sanofi-Synthelabo-Organon, GlaxoSmithKline, Sankyo and Merck.

Dr. Tangelder is at present an employee of Sanofi-Synthelabo. During the preparation of the text for this guideline, he had nothing to declare.

Dr. Verhaeghe has received research support from AstraZeneca AB and Sanofi-Organon.

This is the current release of the guideline.

This guideline updates a previous version: Jackson MR, Clagett GP. Antithrombotic therapy in peripheral arterial occlusive disease. Chest 2001 Jan;119(1 Suppl):283S-299S.

This summary was completed by ECRI on July 30, 2001. The information was verified by the guideline developer on September 27, 2001. This NGC summary was updated by ECRI on December 9, 2004. The updated information was verified by the guideline developer on January 12, 2005. This summary was updated by ECRI Institute on June 22, 2007 following the U.S. Food and Drug Administration (FDA) advisory on heparin sodium injection. This summary was updated by ECRI Institute on March 14, 2008 following the updated FDA advisory on heparin sodium injection.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.