Voyaging to Safety: Anticoagulation in Peripheral Artery Disease and Limb Revascularisation

Abstract

This chapter provides a comprehensive evaluation of the impact of the Vascular Outcomes Study of Acetylsalicylic Acid (ASA) Along with Rivaroxaban in Endovascular or Surgical Limb Revascularization for Peripheral Artery Disease (VOYAGER PAD) trial for the use of the direct acting oral anticoagulant (DOAC) rivaroxaban after surgical revascularisation of lower limb peripheral arterial disease (PAD). The VOYAGER PAD trial, a multinational, double-blind, randomized control trial, evidenced the benefits of a combined low-dose rivaroxaban and aspirin therapy over aspirin alone in reducing major limb adverse events such as acute limb ischemia, major amputations, and cardiovascular-related mortality following surgical revascularisation for severe PAD. However, an increased bleeding risk was also associated with this regimen, particularly in females and patients with a history of bleeding, underscoring the need for careful patient selection, risk stratification, and vigilant monitoring. Special attention is therefore needed when considering this treatment for certain population groups at higher risk of bleeding. Despite these considerations, the results of the trial offer significant promise for improving PAD management and limb revascularization and present numerous opportunities for future research. Investigations into patient-specific factors, precise indications, and dosage optimization could further refine the therapeutic strategies involving rivaroxaban.