This review shows that anticoagulation in PAD is not a simple “more is better” story: low-dose rivaroxaban plus aspirin delivers the clearest reduction in limb and cardiovascular events, but the benefit is tightly linked to patient selection and bleeding risk. The full read is worth it because it maps exactly where dual pathway inhibition is strongest, where full-dose or nonspecific anticoagulation may backfire, and how PAD changes the antithrombotic strategy in real-world settings like revascularization, VTE overlap, and atrial fibrillation.
Abstract: The aim of this paper is to synthesize current evidence regarding the efficacy, safety, and clinical implementation of anticoagulation in patients with PAD, evaluating the impact of different regimens on limb patency, cardiovascular mortality, and bleeding complications across various clinical settings. The review utilises 110 original studies with 2351292 total participants (topic deduplicated ΣN). The evidence map identifies low-dose rivaroxaban plus aspirin as the most consistent anticoagulation-related signal in PAD, with reported reductions of 24% in MACE and 43% to 47% in MALE, alongside a major bleeding increase with hazard ratios around 1.70 to 1.78. This pattern was most persuasive in symptomatic and post-revascularization PAD, where intensified therapy also appeared to reduce total thrombotic events and venous thromboembolism, supporting a practical role for dual pathway inhibition in carefully selected patients. At the same time, the broader evidence base indicates that full-dose or nonspecific anticoagulation strategies do not uniformly translate across PAD contexts, particularly after some endovascular procedures or in younger revascularized cohorts, where harm signals and treatment heterogeneity remain important concerns. In PAD patients with concomitant atrial fibrillation, the mapped literature also supports maintaining indicated oral anticoagulation and suggests DOAC-based strategies may be preferable to warfarin for overall vascular outcomes. Overall, the review supports a selective, risk-stratified approach that balances limb and cardiovascular protection against bleeding risk rather than a uniform escalation of anticoagulation in all PAD patients. Future research should prioritize indication-specific randomized and prospective comparative studies to define optimal regimens for post-intervention PAD, PAD-VTE overlap, and AF-PAD populations, while improving bleeding-risk stratification and real-world implementation.
Keywords: Peripheral artery disease; Anticoagulation therapy; Rivaroxaban; Major adverse limb events; Lower extremity revascularization; Dual pathway inhibition; Major bleeding risk; Venous thromboembolism; Atrial fibrillation; Ankle-brachial index
Review Stats
Final search date and database lock: 2026-04-03 23:33:25 CEST
Plan: Pro (expanded craft tokens; source: PubMed)
Source: PubMed
Total Abstracts/Papers: 386
Downloaded Abstracts/Papers: 386
Included original and non-original Abstracts/Papers (all): 149
Included original Abstracts/Papers (Vote counting by direction of effect): 110
Reference Index (links used in paper): 70
Total participants (topic deduplicated ΣN): 2351292
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