This is the current release of the guideline.

This guideline updates a previous version: Clagett GP, Sobel M, Jackson MR, Lip GY, Tangelder M, Verhaeghe R. Antithrombotic therapy in peripheral arterial occlusive disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004 Sep;126(3 Suppl):609S-26S.

The grades of recommendation (1A, 1B, 1C, 2A, 2B, 2C) are defined at the end of the "Major Recommendations" field.

Chronic Limb Ischemia and Intermittent Claudication

1. In peripheral artery disease (PAD) patients with clinically manifest coronary or cerebrovascular disease, the guideline developers recommend lifelong antiplatelet therapy in comparison to no antiplatelet therapy (Grade 1A).
2. In those without clinically manifest coronary or cerebrovascular disease, the guideline developers suggest aspirin (75–100 mg/day) over clopidogrel (Grade 2B). In patients who are aspirin intolerant, the guideline developers recommend clopidogrel over ticlopidine (Grade 1B).

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

3. In patients with PAD and intermittent claudication, the guideline developers recommend against the use of anticoagulants to prevent vascular mortality or cardiovascular events (Grade 1A).
4. For patients with moderate-to-severe disabling intermittent claudication who do not respond to exercise therapy, and who are not candidates for surgical or catheter-based intervention, the guideline developers recommend cilostazol (Grade 1A). The guideline developers suggest that clinicians not use cilostazol in those with less disabling claudication (Grade 2A). The guideline developers recommend against the use of pentoxifylline (Grade 2B).

   Underlying values and preferences: Because of the cost of cilostazol therapy, and the safety and efficacy of an exercise program, the guideline developers recommend cilostazol treatment be reserved for patients with moderate-to-severe claudication who have tried and failed an exercise program, and are not candidates for vascular surgical or endovascular procedures.

5. For patients with intermittent claudication, the guideline developers recommend against the use of anticoagulants (Grade 1A).
6. For patients with limb ischemia, the guideline developers suggest clinicians do not use prostaglandins (Grade 2B).

Acute Limb Ischemia

1. In patients who suffer from acute arterial emboli or thrombosis, the guideline developers recommend immediate systemic anticoagulation with UFH, over no anticoagulation (Grade 1C). In patients undergoing embolectomy, the guideline developers suggest following systemic anticoagulation with UFH with long-term anticoagulation with VKA (Grade 2C).
2. In patients with short-term (< 14 days) thrombotic or embolic disease, the guideline developers suggest intra-arterial thrombolytic therapy (Grade 2B), provided patients are at low risk of myonecrosis and ischemic nerve damage developing during the time to achieve revascularization by this method.

   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 Bypass Grafts

1. For patients undergoing major vascular reconstructive procedures, the guideline developers recommend intravenous (IV) unfractionated heparin (UFH), prior to the application of vascular cross clamps (Grade 1A).
2. For all patients undergoing infrainguinal arterial reconstruction, the guideline developers recommend aspirin (75–100 mg, begun preoperatively) (Grade 1A). The guideline developers recommend against the routine use of perioperative dextran, heparin, or long-term anticoagulation with vitamin K antagonist (VKA) for all extremity reconstructions (Grade 1B).
3. For patients receiving routine autogenous vein infrainguinal bypass, the guideline developers recommend aspirin (75–100 mg, begun preoperatively) (Grade 1A). The guideline developers suggest that VKA not be used routinely in patients undergoing infrainguinal vein bypass (Grade 2B). 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 relatively little value on small increases in long-term patency that may be statistically uncertain, and a relatively high value on avoiding hemorrhagic complications.

4. For patients receiving routine prosthetic infrainguinal bypass, the guideline developers recommend aspirin (75–100 mg, begun preoperatively) (Grade 1A). The guideline developers suggest that VKA not be used routinely in patients undergoing prosthetic infrainguinal bypass (Grade 2A).

   Underlying values and preferences: These recommendations place relatively little value on small increases in long-term patency that may be statistically uncertain, and a relatively high value on avoiding hemorrhagic complications.

Carotid Endarterectomy

In patients undergoing carotid endarterectomy, the guideline developers recommend that aspirin, 75–100 mg, be given preoperatively to prevent perioperative ischemic neurologic events. The guideline developers recommend lifelong postoperative aspirin (75–100 mg/day) (Grade 1A).

Asymptomatic Carotid Stenosis

1. In nonoperative patients with asymptomatic carotid stenosis (primary or recurrent), the guideline developers recommend lifelong aspirin, 75–100 mg/d (Grade 1C). In this patient group, the guideline developers recommend against dual antiplatelet therapy with aspirin and clopidogrel (Grade 1B).
2. For patients undergoing lower-extremity balloon angioplasty (with or without stenting), the guideline developers recommend long-term aspirin (75–100 mg/day) (Grade 1C). For patients undergoing lower-extremity balloon angioplasty (with or without stenting), the guideline developers recommend against anticoagulation with heparin or VKA (Grade 1A).

Definitions:

*The guideline developers use the wording recommend for strong (Grade 1) recommendations and suggest for weak (Grade 2) recommendations.

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 2008 Jun)

American College of Chest Physicians - Medical Specialty Society

American College of Chest Physicians

American College of Chest Physicians (ACCP) Expert Panel on Antithrombotic and Thrombolytic Therapy

Primary Authors: Michael Sobel, MD; Raymond Verhaeghe, MD

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

Participants: Giancarlo Agnelli, MD; Pierre Amarenco, MD; Jack E. Ansell, MD; Collin Baigent; Shannon M. Bates, MD; Kenneth A. Bauer, MD; Richard C. Becker, MD; Peter B. Berger, MD; David Bergqvist, MD, PhD; Rebecca J. Beyth, MD; Christopher P. Cannon, MD; Elizabeth A. Chalmers, MB, ChB, MD; Anthony K.C. Chan, MBBS; Clifford W. Colwell, Jr., MD; Anthony J. Comerota, MD; Deborah Cook, MD; Mark A. Crowther, MD; James E. Dalen, MD; Gabrielle deVeber, MD, MHSc; Maria Benedetta Donati, MD, PhD; James D. Douketis, MD; Andrew Dunn, MD; J. Donald Easton, MD; Michael Ezekowitz, MD; Margaret Fang; William H. Geerts, MD, FCCP; Alan S. Go, MD; Samuel Z. Goldhaber, MD, FCCP; Shaun D. Goodman, MD; Michael Gould, MD, FCCP; Ian A. Greer, MD; Andreas Greinacher, MD; David Gutterman, MD, FCCP, HSP; Jonathan L. Halperin, MD; John A. Heit, MD; Elaine M. Hylek, MD; Alan Jacobson, MD; Roman Jaeschke, MD, PhD; Amir K. Jaffer, MD; Susan Kahn; Clive Kearon, MBBCh, PhD; Fenella Kirkham, MBBC; Andreas Koster, MD, PhD; Michael R. Lassen, MD; Mark N. Levine, MD, MSc; Sandra Zelman Lewis, PhD; A. Michael Lincoff, MD; Gregory YH Lip, MD; Christopher Madias, MD; Warren J. Manning, MD; Daniel B. Mark, MD; M. Patricia Massicotte, MD, MSc; David Matchar, MD; Thomas W. Meade, DM, FCCP; Venu Menon, MD; Tracy Minichiello, MD; Paul Monagle, MBBS, MSc, MD, FCCP; Christopher M. O'Connor, MD; Patrick O'Gara, MD; E. Magnus Ohman, MD; Ingrid Pabinger, MD; Gualtiero Palareti, MD; Carlo Patrono, MD; Stephen G. Pauker, MD; Graham F. Pineo, MD; Jeffrey J. Popma, MD; Gary Raskob, PhD; Gerald Roth, MD; Ralph L. Sacco, MD; Deeb N. Salem, MD, FCCP; Charles-Marc Samama, MD, FCCP; Meyer Michel Samama, MD; Sam Schulman, MD, PhD; Daniel Singer, MD; Michael Sobel, MD; Shoshanna Sofaer, DrPH; Alex C. Spyropoulos, MD FCCP; Ph. Gabriel Steg, MD; Philip Teal, MD; Raymond Verhaeghe, MD; David A. Vorchheimer, MD; Theodore E. Warkentin, MD; Jeffrey Weitz, MD

Dr. Sobel discloses that he has received grant monies from the National Institutes of Health and the Department of Veterans Affairs.

Professor Verhaeghe discloses that he has received grant monies from Bayer, LEO Pharma, and Sanofi-Aventis.

American College of Clinical Pharmacy - Medical Specialty Society
American Society of Health-System Pharmacists - Professional Association

This is the current release of the guideline.

This guideline updates a previous version: Clagett GP, Sobel M, Jackson MR, Lip GY, Tangelder M, Verhaeghe R. Antithrombotic therapy in peripheral arterial occlusive disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004 Sep;126(3 Suppl):609S-26S.

None available

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 was updated by ECRI Institute on December 2, 2008. The updated information was verified by the guideline developer on January 7, 2009.

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