Underuse of Factor Xa Inhibitors Following Peripheral Vascular Intervention

Most patients that are eligible for oral factor Xa inhibitor therapy following peripheral vascular intervention (PVI) for symptomatic lower extremity peripheral artery disease (LE-PAD) do not receive it, according to study findings published in the Journal of Vascular Surgery.

Investigators sought to explore factor Xa inhibitor initiation following PVI trends over time and identify patient and procedural characteristics related to factor Xa inhibitor use. They conducted a retrospective cross-sectional study using de-identified data from the Vascular Quality Initiative PVI registry. Data were from January 2018 through June 2022. Predictors of factor Xa inhibitor initiation following PVI were determined using multivariate logistic regression. Patients on preoperative anticoagulation therapy, with history of stroke, or with end-stage renal disease requiring dialysis were excluded from the study, as were patients who were aged younger than 50 years.

The investigators found that 51.0% of the 179,494 included PVI procedures had patients that were eligible for factor Xa inhibitor therapy postprocedure. Among those eligible following PVI, initiation of factor Xa inhibitors increased from 3.5% in 2018 to 9.1% in 2022 (P <.0001). After adjusting for confounding variables, this increase remained significant.

Patients who were prescribed factor Xa inhibitor therapy following PVI had the following characteristics:

• mean age, 68.4±9.9 years
• 40.5% were women
• 77.0% were White
• 16.2% were Black
• 43.1% were current smokers
• 84.5% had hypertension
• 35.3% had coronary artery disease
• 58.3% had elective PVI
• 33.4% had nonelective PVI
• 8.3% had emergent PVI

Emergent PVI and nonelective PVI were the strongest positive predictors of factor Xa inhibitor initiation following PVI (odds ratio [OR], 8.20 [95% CI, 7.14-9.41]; and OR, 4.36 [95% CI, 4.06-4.68], respectively; all P <.0001). Additional positive predictors included female gender (OR, 1.10; 95% CI, 1.03-1.18) and being a current smoker (OR, 1.24; 95% CI, 1.12-1.38).

The strongest negative predictor for factor Xa inhibitor initiation was postoperative dual antiplatelet therapy (OR, 0.20; 95% CI, 0.17-0.23; P <.0001). Additional negative predictors included preoperative statin use (OR, 0.93; 95% CI, 0.86-1.00) and being age 70 to 76 years (OR, 0.86; 95% CI, 0.77-0.95) and 77 years or older (OR, 0.77; 95% CI, 0.69-0.86).

Study limitations include the unavailability of data for history of major bleeding, which may have influenced providers’ choice to initiate factor Xa inhibitors, and lack of information on use of low or high-dose treatment with factor Xa inhibitor.

“Factor Xa inhibitor initiation after PVI has increased in recent years, although the absolute rate remains low, and the vast majority of eligible patient are not prescribed this treatment,” the study authors wrote. “This study highlights the limited translation of VOYAGER PAD findings into clinical practice.”