title: Safety and efficacy of periprocedural anticoagulation with enoxaparin in patients undergoing peripheral endovascular revascularization.
abstract: BACKGROUND
  Periprocedural anticoagulation is primarily used in endovascular procedures to prevent acute reocclusion of the target vessel, but periprocedural anticoagulation might also have an impact on long-term outcome. Consecutive bleeding events are feared complications. Despite changes in peripheral endovascular revascularizations (EVRs), the periprocedural management has remained unchanged for years. Unfractionated heparin is still the treatment of choice during and immediately after EVR.
  
  
  METHODS
  We performed a prospective, single-center, open-label phase III study comparing 2 different regimes of enoxaparin peri-interventional to peripheral EVR stratified into low- and high-risk groups according to the acute and long-term reocclusion risk due to their vessel morphology. In both groups, 0.5 mg/kg of enoxaparin as a bolus was administered intravenously 10 to 15 minutes before the start of the procedure. In the low-risk group, 40 mg of enoxaparin were administered once daily for 7 days; whereas in the high-risk group, 1 mg/kg of enoxaparin was administered subcutaneously (sc) 2 times a day for 48 hours after the procedure and afterward 40 mg of enoxaparin was administered sc once daily for 5 days.
  
  
  RESULTS
  For the analysis of the per protocol population, 44 patients remained in the low-risk group and 140 in the high-risk group. Concerning the primary safety end point, a total of 25 (13.59%) bleeding events occurred until day 30; 5 (11.36%) of them in the low-risk group and 20 (14.29%) in the high-risk group (P = .809 for low vs high risk). None of the bleeding events observed were major according to Thrombolysis In Myocardial Infarction criteria. Concerning our primary efficacy end point, none of the patients showed an acute reocclusion classified as a significant decrease in ankle-brachial index (ABI) or elevated peak systolic velocity ratio confirmed by duplex sonography until day 30. Concerning the second end point of prevention of chronic reobstruction, at day 180 ABI has decreased in the low-risk group from mean 0.94 at day 30 to mean 0.89 and from 1.28 at day 30 to 0.85 after 6 months in the high-risk group. No significant reobstruction was found in the low-risk group, whereas 5 significant reobstruction events were objectified in the high-risk group, all of them in the femoropopliteal arterial segment at day 180.
  
  
  CONCLUSIONS
  We conclude that low-molecular-weight heparin either in a low-dose or high-dose regime during a peripheral EVR is safe concerning bleeding complications and acute reobstructions. The long-term follow-up showed no significant difference between our high- and low-risk groups concerning reobstruction. The periprocedural anticoagulation seems to have no influence on the long-term patency rate after peripheral EVR.
authors.affiliation: Division of Angiology, Medical University Graz, Graz, Austria marianne.brodmann@medunigraz.at.
authors.forename: Marianne
authors.initials: M
authors.lastname: Brodmann
authors.affiliation: Division of Angiology, Medical University Graz, Graz, Austria.
authors.forename: A
authors.initials: A
authors.lastname: Dorr
authors.affiliation: Division of Angiology, Medical University Graz, Graz, Austria.
authors.forename: F
authors.initials: F
authors.lastname: Hafner
authors.affiliation: Division of Angiology, Medical University Graz, Graz, Austria.
authors.forename: T
authors.initials: T
authors.lastname: Gary
authors.affiliation: Division of Angiology, Medical University Graz, Graz, Austria.
authors.forename: H
authors.initials: H
authors.lastname: Froehlich
authors.affiliation: Independent Biostatistics, Graz, Austria.
authors.forename: E
authors.initials: E
authors.lastname: Kvas
authors.affiliation: Division of Interventional Radiology, Medical University Graz, Graz, Austria.
authors.forename: H
authors.initials: H
authors.lastname: Deutschmann
authors.affiliation: Division of Angiology, Medical University Graz, Graz, Austria.
authors.forename: E
authors.initials: E
authors.lastname: Pilger
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects; D057510:Endovascular Procedures; D017984:Enoxaparin / Q000008:administration & dosage* / Q000009:adverse effects; D005260:Female; D006470:Hemorrhage / Q000139:chemically induced / Q000628:therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D019990:Perioperative Care / Q000379:methods*; D013997:Time Factors
chemical_list: D000925:Anticoagulants; D017984:Enoxaparin
keywords: acute reocclusion; bleeding; endovascular intervention; low-molecular-weight heparin; periinterventional complications; peripheral arterial occlusive disease