The Value of Screening for HPR in Patients Undergoing Lower Extremity Arterial Endovascular Interventions

Peripheral arterial disease (PAD) affects millions of people worldwide. Management of PAD has evolved from open surgery to an endovascular first approach leading to increased volume of endovascular interventions. Endovascular femoropopliteal intervention has emerged as a standard treatment for symptomatic PAD with acceptable patency rates.

Histologic observation of bare metal stents with early failure shows association with platelet rich thrombus, high counts of platelets, and neutrophils associated with stent struts. Additionally, high inflation pressures associated with balloon angioplasty often causes local tissue damage leading to platelet activation. These findings led to studies targeting platelet activation following endovascular treatment showing improved outcomes in patients receiving stronger platelet inhibition.

The current standard of care is prescription of dual antiplatelet therapy (DAPT) for femoropopliteal angioplasty or stenting. DAPT is active use of any two antiplatelet agents, often low dose aspirin plus P2Y12 inhibitor (clopidogrel, ticagrelor, prasugrel). There is improved stent patency and reduced adverse cardiovascular events in patients taking DAPT versus aspirin monotherapy.

Clopidogrel is the most common additional antiplatelet agent prescribed, but 4-65% of patients taking clopidogrel fail to achieve clinically expected platelet inhibition. This persistent platelet reactivity despite compliant antiplatelet use is commonly referred to as high on-treatment platelet reactivity (HPR), and increases risk of endovascular intervention failure and associated adverse clinical events in these patients. Clopidogrel is a pro-drug metabolized by CYP2C19 enzyme into its active form. Failure to respond appropriately to clopidogrel is largely due to genetic polymorphisms within CYP2C19 enzyme resulting in variable metabolization of clopidogrel into the active metabolite.

Alternative antiplatelet medications can overcome HPR through different metabolic pathways, but unfortunately at a significantly higher cost. Of these, ticagrelor is often used to overcome HPR for patients taking clopidogrel with favorable outcomes. However, regional cost for ticagrelor is $352.50 compared to $1.96 for clopidogrel. Cost and bleeding concerns among providers have prevented widespread use. Overall, there is paucity of evidence looking at HPR and lower extremity arterial endovascular interventions without consensus or guidelines on how to address this problem. Thus, the investigators propose an unblinded, randomized controlled trial in patients having femoropopliteal angioplasty or stenting comparing two strategies: 1. testing and treating for HPR versus 2. guideline based therapy without testing for HPR.