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Evidenzbasierte antithrombotische Therapie der peripheren arteriellen Verschlusskrankheit (PAVK)

Ein kritischer Überblick und Update

Evidence-based antithrombotic treatment of peripheral arterial occlusive disease (PAOD)

A critical review and update

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Zusammenfassung

Die evidenzbasierte leitliniengerechte antithrombotische Therapie von Patient:innen mit peripherer arterieller Verschlusskrankheit (PAVK) stellt seit langer Zeit eine Herausforderung im klinischen Alltag von Gefäßmediziner:innen dar. Erstmals wird 2023 eine Praxisleitlinie der European Society for Vascular Surgery (ESVS) erwartet, die sich explizit mit der antithrombotischen Therapie von Patient:innen mit Gefäßkrankheiten befasst. Viele Entscheidungen und Leitlinienempfehlungen wurden bisher auf dem Boden von Studien aus anderen Fachbereichen generiert, da keine geeignete hochwertige Evidenzbasis existiert. In den vergangenen Jahren sind innovative Studiendaten veröffentlicht worden, die neue Erkenntnisse, aber auch neue Herausforderungen eingeführt haben. Dieser Artikel gibt eine Übersicht über die derzeitige Studienlage und deren Praxisrelevanz. Speziell wird dabei auf die unterschiedlichen Behandlungsoptionen (konservativ, endovaskulär, offen-chirurgisch) und die diffizile Abwägung von Wirksamkeit gegen Sicherheit eingegangen. Die für und wider von Kombinationsendpunkten aktueller Studien werden ebenso diskutiert, wie der immanente Selektionsbias und das Risiko für schwere Blutungen. Gleichzeitig soll aber auch die derzeitige Versorgungsrealität einschließlich der Verschreibungspraxis dargestellt werden.

Abstract

The evidence-based guideline-compliant antithrombotic treatment of patients with peripheral arterial occlusive disease (PAOD) has for a long time been a challenge in the routine clinical practice of vascular specialists. For the first time in 2023 clinical practice guidelines of the European Society for Vascular Surgery (ESVS) that explicitly deal with the antithrombotic treatment of patients with vascular diseases are expected. Many decisions and guideline recommendations have been based on studies from other medical specialties as no suitable evidence base exists. Most recently, innovative studies were published that introduced more knowledge but also new challenges for healthcare professionals. This article provides an overview of the current study situation and its relevance in clinical practice. Thereby, it explicitly discusses the different treatment options (conservative, endovascular, open surgery) and the difficult balance between efficacy and safety of antithrombotic drugs. The advantages and disadvantages of composite endpoints of current studies as well as the inherent selection bias and risk for major bleeding events are meticulously discussed. Simultaneously, the current treatment reality including the prescription practice is also presented.

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Authors and Affiliations

  1. Klinik für Allgemeine und Endovaskuläre Gefäßchirurgie, Asklepios Klinik Wandsbek, Asklepios Medical School Hamburg, Alphonsstraße 14, 22043, Hamburg, Deutschland

    Christian-Alexander Behrendt

  2. Deutsches Institut für Gefäßmedizinische Gesundheitsforschung gGmbH (DIGG), Berlin, Deutschland

    Christian-Alexander Behrendt

  3. Klinik für Gefäßchirurgie und endovaskuläre Chirurgie, Asklepios Klinik Altona, Asklepios Medical School Hamburg, Hamburg, Deutschland

    Axel Larena-Avellaneda

  4. Klinik für Gefäßchirurgie, Uniklinik RWTH Aachen, Aachen, Deutschland

    Alexander Gombert

  5. Abteilung für Gefäßchirurgie, Universitätsklinik Erlangen, Erlangen, Deutschland

    Ulrich Rother

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  1. Christian-Alexander Behrendt
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  2. Axel Larena-Avellaneda
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  3. Alexander Gombert
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  4. Ulrich Rother
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Correspondence to Christian-Alexander Behrendt.

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Interessenkonflikt

C.-A. Behrendt ist Co-Chair der 2024 European Society for Vascular Surgery (ESVS) Clinical Practice Guidelines on Asymptomatic PAD and Intermittent Claudication und Steuergruppenmitglied der AWMF S3-Leitlinie zur Diagnostik und Therapie der PAVK, der 2023 ESVS Clinical Practice Guidelines on Antithrombotic Therapy for Vascular Diseases, sowie der Intersociety Guidelines on CLTI and Diabetic Foot der International Working Group of the Diabetic Foot (IWGDF). U. Rother ist Steuergruppenmitglied der AWMF S3-Leitlinie zur Diagnostik und Therapie der PAVK und der 2024 ESVS Clinical Practice Guidelines on Asymptomatic PAD and Intermittent Claudication. Alle Autoren geben an, dass keine Interessenkonflikte bestehen. A. Larena-Avellaneda und A. Gombert geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autor/-innen keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Behrendt, CA., Larena-Avellaneda, A., Gombert, A. et al. Evidenzbasierte antithrombotische Therapie der peripheren arteriellen Verschlusskrankheit (PAVK). Gefässchirurgie 28, 208–215 (2023). https://doi.org/10.1007/s00772-023-00992-8

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