Patients being prescribed antithrombotic therapy are recommended to have a bleeding risk assessment performed to aid shared decision making. | Grade / classClass I, Level C |
Patients with a modifiable risk of bleeding being prescribed antithrombotic therapy are recommended to have adequate management to limit the corresponding bleeding risk. | Grade / classClass I, Level C |
Patients taking antithrombotic therapy with a history of upper digestive tract lesions, or who are at higher risk of gastrointestinal bleeding, should be considered for proton pump inhibitor therapy to reduce the risk of gastrointestinal bleeding. | Grade / classClass IIa, Level C |
Patients receiving unfractionated heparin infusions are recommended to have the activated partial thromboplastin time or activated partial thromboplastin time ratio monitored to reduce the risk of bleeding. | Grade / classClass I, Level C |
Patients undergoing open or endovascular arterial intervention being administered a bolus of unfractionated heparin may be considered for activated partial thromboplastin time, activated partial thromboplastin time ratio or activated clotting time monitoring as a measure of anticoagulation. | Grade / classClass IIb, Level C |
Patients with asymptomatic > 50% carotid artery stenoses are recommended to be offered aspirin (75 – 325 mg) to reduce the risk of secondary cardiovascular events. | Grade / classClass I, Level B |
Patients with asymptomatic > 50% carotid artery stenoses who are intolerant or allergic to aspirin should be offered clopidogrel (75 mg) to reduce the risk of secondary cardiovascular events. If allergic to both aspirin and clopidogrel, dipyridamole (200 mg twice daily) should be considered. | Grade / classClass IIa, Level C |
Patients with transient ischaemic attack or minor ischaemic stroke with any degree of carotid artery stenosis not undergoing carotid endarterectomy or stenting are recommended to have dual antiplatelet therapy with aspirin (75 – 325 mg) and clopidogrel (75 mg) for 21 days followed by clopidogrel 75 mg, or long term aspirin (75 – 100 mg) plus dipyridamole (200 mg twice daily) to reduce the risk of stroke. | Grade / classClass I, Level A |
Patients intolerant or allergic to clopidogrel with transient ischaemic attack or minor ischaemic stroke with any degree of carotid artery stenosis not undergoing carotid endarterectomy or stenting should be considered for dual antiplatelet therapy with aspirin and ticagrelor (30 days) or aspirin and dipyridamole (14 days) as an alternative to aspirin and clopidogrel to reduce the risk of stroke. | Grade / classClass IIa, Level B |
Protocols for antiplatelet therapy for symptomatic patients prior to carotid endarterectomy or stenting should be made by local teams. Doses should follow the major randomised trial regimens. | Grade / classClass I, Level C |
Patients who are to undergo carotid endarterectomy are recommended to have antiplatelet therapy before the procedure, in the peri-operative period, and over the long term. | Grade / classClass I, Level A |
Patients with a > 50% carotid stenosis experiencing transient ischaemic attack or minor stroke awaiting carotid endarterectomy are recommended for early institution of antiplatelet therapy to reduce recurrent stroke risk. | Grade / classClass I, Level B |
Recently symptomatic patients who are to undergo carotid endarterectomy should be considered for dual antiplatelet therapy with aspirin (75 – 325 mg) and clopidogrel (75 mg) peri-operatively to reduce recurrent stroke risk. | Grade / classClass IIa, Level C |
Recently symptomatic patients who are to undergo carotid endarterectomy for whom antiplatelet monotherapy is preferred should be considered for aspirin (300 – 325 mg daily) for 14 days followed by lower doses (75 – 162 mg daily) to reduce the recurrent stroke risk. | Grade / classClass IIa, Level B |
Patients who are to undergo carotid endarterectomy are recommended to preferentially have low dose aspirin (75 – 325 mg daily) rather than higher doses to reduce recurrent stroke risk. | Grade / classClass I, Level B |
Patients scheduled for carotid artery stenting for carotid stenosis are recommended to have dual antiplatelet therapy consisting of aspirin (75 – 325 mg) plus clopidogrel (75 mg) to reduce recurrent stroke risk. Clopidogrel should be started at least three days before stenting or as a single 300 mg loading dose in urgent cases. | Grade / classClass I, Level C |
Patients undergoing carotid artery stenting are recommended to have dual antiplatelet therapy with aspirin and clopidogrel continued for at least four weeks after carotid stenting, then clopidogrel 75 mg continued indefinitely to reduce stroke risk. | Grade / classClass I, Level C |
Patients with ischaemic cerebral events both undergoing and not undergoing carotid intervention are not recommended to have dual antiplatelet therapy with aspirin and clopidogrel long term as it confers no benefit over single antiplatelet therapy but increases the bleeding risk. | Grade / classClass III, Level A |
Patients with chronic symptomatic upper limb arterial disease should be considered for single antiplatelet therapy for secondary prevention of cardiovascular events. | Grade / classClass IIa, Level C |
Patients post-revascularisation for upper limb atherosclerotic arterial disease are recommended to have an individualised antithrombotic strategy balancing risks and benefits to reduce the risk of secondary cardiovascular and limb events. | Grade / classClass I, Level C |
Patients with asymptomatic or symptomatic > 50% atherosclerotic renal or mesenteric artery stenotic disease should be considered for single antiplatelet therapy for secondary prevention of cardiovascular events. | Grade / classClass IIa, Level C |
Patients post-revascularisation for atherosclerotic renal or mesenteric artery disease who are not at high risk of bleeding should be considered for a short course (minimum of one to maximum six months) dual antiplatelet therapy (aspirin 75 mg and clopidogrel 75 mg) to reduce the risk of stent thrombosis. | Grade / classClass IIa, Level C |
Patients with isolated asymptomatic lower extremity artery disease are not recommended to have aspirin for cardiovascular prevention. | Grade / classClass III, Level A |
Patients with chronic symptomatic lower extremity arterial disease are recommended to have single antiplatelet therapy for secondary cardiovascular prevention. | Grade / classClass I, Level A |
Patients with chronic symptomatic lower extremity arterial disease should be considered for clopidogrel (75 mg) as the first choice antiplatelet agent when single antiplatelet therapy is indicated for secondary cardiovascular prevention. | Grade / classClass IIa, Level B |
Patients with chronic symptomatic lower extremity arterial disease are not recommended to have dual antiplatelet therapy for secondary cardiovascular prevention. | Grade / classClass III, Level B |
Patients with chronic lower extremity arterial disease with no other indication for anticoagulation are not recommended to have full dose anticoagulation for secondary cardiovascular prevention. | Grade / classClass III, Level A |
Patients with chronic symptomatic lower extremity arterial disease who are not at high risk of bleeding, especially those at higher ischaemic risk, should be considered for aspirin (75 – 100 mg once daily) in combination with rivaroxaban (2.5 mg twice daily) for secondary cardiovascular and major adverse limb event risk reduction. | Grade / classClass IIa, Level B |
Patients with acute limb ischaemia are recommended to have immediate intravenous unfractionated or low molecular weight heparin to reduce the risk of thrombus propagation. | Grade / classClass I, Level C |
Patients with acute limb ischaemia planned for expedited revascularisation are recommended to have immediate intravenous unfractionated heparin to reduce the risk of thrombus propagation. | Grade / classClass I, Level C |
Patients undergoing endovascular arterial intervention are recommended to have a single bolus of intravenous or intra-arterial unfractionated (50 – 100 IU/kg) or low molecular weight (0.5 mg/kg) heparin to reduce the risk of peri-operative acute limb events. | Grade / classClass I, Level B |
Patients undergoing open arterial surgery should be considered for a single bolus of intravenous or intra-arterial unfractionated heparin (50 – 100 IU/kg) to reduce the risk of peri-operative acute limb events. | Grade / classClass IIa, Level C |
Patients undergoing endovascular or open arterial surgery may be considered for intra-operative activated partial thromboplastin time, activated partial thromboplastin time ratio, or activated clotting time measurement to guide further doses or reversal of unfractionated heparin. | Grade / classClass IIb, Level C |
Patients undergoing endovascular arterial intervention may be considered for a single dose of bivalirudin (0.75 mg/kg) as an alternative to heparin to reduce the risk of peri-operative acute limb events. | Grade / classClass IIb, Level B |
Patients undergoing endovascular intervention for lower extremity arterial disease who are not at high risk of bleeding may be considered for a short course (a minimum of one to maximum six months) dual antiplatelet therapy (aspirin 75 mg plus clopidogrel 75 mg) to reduce the risk of secondary cardiovascular and major adverse limb events. | Grade / classClass IIb, Level C |
Patients undergoing endovascular intervention for lower extremity arterial disease who are not at high risk of bleeding should be considered for aspirin (75 – 100 mg once daily) combined with rivaroxaban (2.5 mg twice daily) to reduce the risk of secondary cardiovascular and major adverse limb events. | Grade / classClass IIa, Level B |
If clopidogrel (75 mg) is added in exceptional circumstances to aspirin (75 – 100 mg once daily) in combination with rivaroxaban (2.5 mg twice daily) for patients undergoing endovascular intervention for lower extremity arterial disease who are not at high risk of bleeding, it is not recommended for longer than 30 days as the bleeding risk is likely to outweigh the benefit. | Grade / classClass III, Level C |
Patients undergoing infrainguinal endarterectomy or bypass using autologous vein or prosthetic conduit for lower extremity arterial disease who are not at high risk of bleeding should be considered for aspirin (75 – 100 mg once daily) in combination with rivaroxaban (2.5 mg twice daily) to reduce the risk of secondary cardiovascular and major adverse limb events. | Grade / classClass IIa, Level B |
If clopidogrel (75 mg) is added in exceptional circumstances to aspirin (75 – 100 mg once daily) in combination with rivaroxaban (2.5 mg twice daily) for patients undergoing infrainguinal bypass surgery using autologous vein or prosthetic conduit for lower extremity arterial disease who are not at high risk of bleeding, it is not recommended for longer than 30 days as the bleeding risk is likely to outweigh the benefit. | Grade / classClass III, Level C |
Patients undergoing infrainguinal bypass with autologous vein for lower extremity arterial disease who are not at high risk of bleeding may be considered for vitamin K antagonists to improve graft patency. | Grade / classClass IIb, Level A |
Patients taking a vitamin K antagonist to improve patency of an infrainguinal vein bypass graft should have an international normalised ratio of 2.0 – 3.0 with a target of 2.5. | Grade / classClass IIa, Level C |
Patients undergoing infrainguinal bypass surgery with a prosthetic conduit for lower extremity arterial disease may be considered for single antiplatelet therapy to improve graft patency. | Grade / classClass IIb, Level B |
Patients at high risk of bleeding undergoing infrainguinal bypass using an autologous vein or prosthetic conduit for lower extremity arterial disease may be considered for single antiplatelet therapy to improve graft patency. | Grade / classClass IIb, Level C |
Patients experiencing arterial embolus of unknown origin who are not at high risk of bleeding may be considered for long term therapeutic anticoagulation to reduce the risk of recurrent embolic events. | Grade / classClass IIb, Level C |
Patients with a small abdominal aortic aneurysm may be considered for aspirin (75 – 100 mg) to reduce the risk of cardiovascular events. | Grade / classClass IIb, Level C |
Patients undergoing endovascular or open abdominal aortic aneurysm repair should be considered for aspirin (75 – 100 mg) following repair to reduce the risk of secondary cardiovascular events. | Grade / classClass IIa, Level B |
Patients with popliteal aneurysms should be considered for single antiplatelet therapy to reduce the risk of major adverse limb events. | Grade / classClass IIa, Level C |
Patients undergoing open popliteal aneurysm repair may be considered for single antiplatelet therapy post-operatively to reduce the risk of major adverse limb events. | Grade / classClass IIb, Level C |
Patients with extracranial carotid or vertebral artery dissection are recommended to have single antiplatelet therapy for at least three months to reduce the risk of subsequent ischaemic stroke. | Grade / classClass I, Level B |
Patients with isolated superior mesenteric artery dissection should be considered for single antiplatelet therapy to reduce the risk of ischaemic small bowel events. | Grade / classClass IIa, Level C |
Patients undergoing arteriovenous fistula or graft formation are not recommended to have systemic unfractionated heparin because of the increased risk of bleeding and lack of benefit for patency. | Grade / classClass III, Level A |
Patients undergoing formation of an arteriovenous fistula should be considered for clopidogrel (75 mg) for up to six months as the first line antiplatelet agent to improve fistula patency. | Grade / classClass IIa, Level B |
Patients undergoing formation of an arteriovenous fistula may be considered for aspirin (75 – 100 mg) for up to six months to improve fistula patency if clopidogrel is contraindicated. | Grade / classClass IIb, Level A |
Patients undergoing formation of a non-autologous arteriovenous graft may be considered for single antiplatelet therapy for up to six months to improve graft patency. | Grade / classClass IIb, Level C |
Patients with chronic kidney disease (estimated glomerular filtration rates ≥ 30 mL/min/1.73m2) requiring anticoagulation for a peripheral arterial disease indication may be considered for direct oral anticoagulants, and patients with a glomerular filtration rate < 30 mL/min/ 1.73m2, may be considered for vitamin K antagonists; however, the risk balance is complex and must be strictly individualised. | Grade / classClass IIb, Level C |
Patients with chronic kidney disease (estimated glomerular filtration rates ≥ 30 mL/min/1.73m2) requiring anticoagulation for the prevention of recurrent venous thromboembolism should be considered for direct oral anticoagulants. | Grade / classClass IIa, Level B |
Patients with chronic kidney disease stage 3 or 4 (estimated glomerular filtration rates from 15 to 59 mL/min/1.73m2) requiring anticoagulation with low molecular weight heparin should be considered for regular monitoring of renal function and dose adjustment to reduce the risk of bleeding. | Grade / classClass IIa, Level C |
Patients with chronic peripheral artery disease and a cardiac or vascular indication for full dose anticoagulation are not recommended to have antiplatelet therapy routinely added to anticoagulation. | Grade / classClass III, Level B |
Patients taking antiplatelet therapy for any peripheral arterial disease indication should have the antiplatelet therapy stopped if full dose anticoagulation becomes indicated for another reason. | Grade / classClass III, Level B |
Patients with a pre-existing indication for full dose anticoagulation undergoing endovascular intervention may be exceptionally considered for the addition of single antiplatelet therapy for a maximum of three months to reduce the risk of subsequent ischaemic events. | Grade / classClass IIb, Level C |
Patients with antiphospholipid syndrome presenting with an arterial embolic event are recommended to have anticoagulation with vitamin K antagonists with a target INR of 2 – 3 to reduce the risk of future thromboembolic events. | Grade / classClass I, Level C |
Patients undergoing any vascular procedure are recommended to have an individually personalised venous thromboembolism risk assessment. | Grade / classClass I, Level C |
Patients with proximal deep vein thrombosis are recommended to have a three month course of a full dose direct oral anticoagulant rather than a vitamin K antagonist to reduce the risk of recurrent thromboembolic events. | Grade / classClass I, Level A |
Patients with a proximal deep vein thrombosis requiring extended anticoagulation following the principal three month treatment phase should be considered for full dose direct oral anticoagulants rather than vitamin K antagonists to reduce the risk of further thromboembolic events. | Grade / classClass IIa, Level B |
Patients with unprovoked deep vein thrombosis who are eligible for anticoagulants are not recommended to have aspirin for extended antithrombotic therapy to reduce the risk of thromboembolic events. | Grade / classClass III, Level A |
Patients with a first episode of unprovoked proximal deep vein thrombosis not deemed to be at high risk of recurrence should be considered for reduced dose apixaban (2.5 mg twice daily) or rivaroxaban (10 mg once daily) after the principal three month treatment phase to reduce the risk of further thromboembolic events. | Grade / classClass IIa, Level B |
Patients with lower limb superficial vein thrombosis ≥ 3 cm away from the junction with the deep veins and extending ≥ 5 cm in length are recommended to have fondaparinux 2.5 mg once daily for 45 days to reduce the risk of further thromboembolic events. | Grade / classClass I, Level B |
Patients with lower limb superficial vein thrombosis ≥ 3 cm away from the junction with the deep veins and extending ≥ 5 cm in length should be considered for rivaroxaban 10 mg or an intermediate dose of a low molecular weight heparin once daily as an alternative to fondaparinux to reduce the risk of further thromboembolic events. | Grade / classClass IIa, Level B |
Patients with lower limb superficial vein thrombosis ≤ 3 cm from the junction with the deep veins are recommended to have three months of full dose anticoagulation to reduce the risk of further thromboembolic events. | Grade / classClass I, Level C |
Patients with superficial vein thrombosis of the leg who exhibit high risk clinical and or anatomical features (such as clinically extensive superficial vein thrombosis involving both the calf and the thigh, absence of local pain, superficial axial vein thrombosis or multiple thrombosed venous sites) may be considered for a three month (rather than 45 day) course of intermediate dose anticoagulation to reduce the risk of further thromboembolic events. | Grade / classClass IIb, Level C |
Patients with cancer associated venous thromboembolism are recommended to have anticoagulation with low molecular weight heparin to reduce the risk of further thromboembolic events. | Grade / classClass I, Level A |
Patients with cancer associated venous thromboembolism and a low risk of gastrointestinal or genitourinary bleeding are recommended to be considered for anticoagulation with a direct oral anticoagulant preferably apixaban, alternatively rivaroxaban or edoxaban. | Grade / classClass I, Level A |
Patients with superficial venous incompetence undergoing high ligation and stripping of the great saphenous vein who are thought to be at higher risk of deep vein thrombosis should be considered for thromboprophylaxis with a low molecular weight heparin to prevent post-operative venous thromboembolism. | Grade / classClass IIa, Level B |
Patients with superficial venous incompetence undergoing endovenous ablation of the great saphenous vein who are thought to be at higher risk of deep vein thrombosis should be considered for thromboprophylaxis with a low molecular weight heparin to prevent post-operative venous thromboembolism. | Grade / classClass IIa, Level C |
Patients undergoing iliofemoral venous stenting for deep venous disease should be considered for an individualised antithrombotic regimen considering the risk of bleeding associated with more aggressive antithrombotic strategies. | Grade / classClass IIa, Level C |
Patients undergoing intervention for deep vein thrombosis (with or without stenting) are recommended to have a duration of anticoagulation at least as long as standard treatment following deep vein thrombosis to prevent recurrent thromboembolic events. | Grade / classClass I, Level C |
Patients with extensive venous malformation or Klippel Trenaunay syndrome with evidence of localised intravascular coagulopathy confirmed by low fibrinogen and high D dimer levels may be considered for prophylactic anticoagulation (low molecular weight heparin or direct oral anticoagulant) for 10 days before, and 20 days after, any invasive procedure to prevent progression to disseminated intravascular coagulation. | Grade / classClass IIb, Level C |
Patients with venous malformation associated coagulopathy are not recommended to have antiplatelet agents to prevent progression to disseminated intravascular coagulation. | Grade / classClass III, Level C |
Anti-factor Xa monitoring is not necessary, except in obese patients and particularly in those with renal failure. | Grade / classnone printed |
Its long half life of around 17 hours permits once daily injections of 2.5 mg for prophylaxis, but requires anti-factor Xa monitoring in chronic kidney disease (CKD). | Grade / classnone printed |
As a consequence, overlapping heparin treatment is mandatory in most cases when initially starting a VKA, except for atrial fibrillation. | Grade / classnone printed |
Additionally, dabigatran is a substrate of the P-glycoprotein drug transporter, therefore its use should be monitored and it should not be used together with medications that inhibit or induce P-glycoprotein such as ketoconazole, amiodarone, and quinidine. It is eliminated renally so its use should be monitored in patients with renal dysfunction (Table 6). | Grade / classnone printed |
While immediate reversal may be necessary in emergency situations before endovascular procedures, stopping a DOAC 48 hours prior to the procedure is usually sufficient for elective procedures. | Grade / classnone printed |
There have been no specific trials evaluating the effect of antiplatelet therapy in patients with asymptomatic or symptomatic vertebral stenosis; however, given their risk profile, it is reasonable to adopt the same recommendation strategy as for carotid disease. | Grade / classnone printed |
In line with recommendations in section 4, antiplatelet or anticoagulant therapy is generally not recommended for asymptomatic disease. Following intervention it is reasonable to follow the recommendations in section 4.5.5. | Grade / classnone printed |
Finally, when heparin is used for patients with CKD, dose adjustment must be performed as per local protocol as there is no randomised evidence for dose adjustment. Therefore, expert opinion practice recommends decreasing the initial standard dose by 33%, and subsequent dose adjustment should be based on APTT levels. | Grade / classnone printed |
Decisions for both investigating potential thrombophilia, and subsequent antithrombotic therapy, should therefore only be made with a specialist haematologist. If there is no clear precipitating event for an embolus, consideration for thrombophilia testing should only be performed after three months of anticoagulation, if at all. There is clear consensus that testing should be highly selective to avoid misdiagnosis and potential overtreatment, so should only be performed by a specialist in this area. | Grade / classnone printed |
Likewise, patients who are at very high risk of VTE not on aggressive regimens should be considered for longer courses (up to six weeks post-operatively) of prophylactic LMWH. | Grade / classnone printed |
Finally, patients with deep vein thrombosis and antiphospholipid syndrome who are triple positive or have a history of arterial or small vessel thrombosis, are not recommended to be treated with direct oral anticoagulants; a VKA should be used instead. DOACs and particularly apixaban or dabigatran may be an appropriate option for low risk APS patients (single or double antibody positive), pending further evidence. | Grade / classnone printed |
Antithrombotic therapy is continued post-operatively, with indefinite anticoagulation recommended for most post-thrombotic patients. | Grade / classnone printed |
Patient centred trial design for future trials of antithrombotic therapy. | Grade / classnone printed |
Work to define and standardise composite endpoints for RCTs of antithrombotic therapy. | Grade / classnone printed |
Work to standardise antithrombotics protocols in RCTs for other areas of vascular intervention such as new endovascular technology. Core outcome and measurement sets would achieve this aim. | Grade / classnone printed |
Work to facilitate RCT research in more vascular registries internationally. | Grade / classnone printed |
Development and validation of bleeding risk assessment tools for patients with PAD and venous disease. | Grade / classnone printed |
Better definitions and quantification of major bleeding considering the patient perspective. | Grade / classnone printed |
Definitions of net benefit – the difference between risks and benefits, again taking multiple stakeholder opinions into account. | Grade / classnone printed |
Further clinical studies on the impact of testing for, and then treating high on treatment platelet reactivity for patients with PAD, focussing on patients with a higher risk of thrombotic events (post-intervention and factors listed in Table 9). | Grade / classnone printed |
RCTs examining antiplatelet regimens, especially dual antiplatelets, before, during and after carotid intervention for symptomatic stenoses. Crescendo TIA should be included. | Grade / classnone printed |
Further RCTs on high ischaemic risk asymptomatic PAD groups to understand any potential magnitude of the effects of antithrombotics other than aspirin. | Grade / classnone printed |
Further clinical studies on high ischaemic risk chronic symptomatic LEAD groups to understand any comparative magnitude of antithrombotics, especially clopidogrel vs. aspirin plus low dose rivaroxaban. | Grade / classnone printed |
RCTs comparing single antiplatelet, dual antiplatelets, and antiplatelet plus low dose anticoagulants after endovascular intervention for LEAD. Focus on high risk groups. | Grade / classnone printed |
RCTs comparing combinations of antiplatelet and anticoagulant following lower limb bypass for LEAD. Focus on high risk groups as well as stratification by arterial territory such as below the knee. | Grade / classnone printed |
RCTs examining the role of antithrombotic therapy for patients with AAA. The most urgent need is for secondary cardiovascular prevention and expansion for patients with small AAA. | Grade / classnone printed |
Cohort or randomised studies on isolated thrombus within the aorta or aortic stent grafts. | Grade / classnone printed |
Clinical studies on the effect of antithrombotic therapy before, during, and after venous stenting. Research collaborations may be the best way to achieve this between high volume practitioners. | Grade / classnone printed |
For patients with SVT, further research should investigate the effectiveness of intermediate doses of LMWHs in reducing VTE (DVT and or PE) vs. placebo. | Grade / classnone printed |
RCTs should be performed to inform clinical practice regarding the optimum treatment duration for patients with SVT near a junction with the deep veins. | Grade / classnone printed |
Further RCTs are required to provide a higher level of evidence for duration of extended anticoagulation following SVT. | Grade / classnone printed |