循環器ジャーナル68巻4号

2020年10月発行

特集 抗血栓療法—日常臨床での疑問に応える Ⅱ．虚血性心疾患・下肢動脈疾患に対する抗血栓療法

下肢虚血に対する抗血小板薬の注意点は？—末梢動脈疾患に対する抗血栓療法について

著者： 飯田修¹

所属機関： ¹関西ろうさい病院循環器内科

ページ範囲：P.624 - P.631

Point
・末梢動脈疾患（peripheral artery disease;PAD）に対する治療戦略は，①PADの新規発症・増悪・再発の予防，②他のアテローム血栓症動脈疾患（心筋梗塞・脳梗塞等）のイベント抑制，③血行再建術（血管内治療/外科手術）の3本柱である．
・抗血小板薬がPAD治療における中心的役割を担ってきていたが，近年直接型経口抗凝固薬（direct oral anticoagulant:DOAC）使用によりイベント抑制が報告され，今後この領域における抗血栓薬に第一選択治療への期待がもたれている．

参考文献

1) Ouriel K:Peripheral arterial disease. Lancet 358:1257-1264, 2001

2) Aboyans V, Ricco JB, Bartelink MEL, et al:ESC Scientific Document Group. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery（ESVS）:Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries. Endorsed by:the European Stroke Organization（ESO）The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology（ESC）and of the European Society for Vascular Surgery（ESVS）. Eur Heart J 39:763-816, 2018

3) Conte MS, Bradbury AW, Kolh P, et al:Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg 69:3S-125S, 2019

4) Norgren L, Hiatt WR, Dormandy JA, et al. Inter-society consensus for the management of peripheral arterial disease（TASC Ⅱ）. J Vasc Surg 2007;45:S5-S67.

5) Mach F, Baigent C, Catapano AL, et al:ESC Scientific Document Group. 2019 ESC/EAS Guidelines for the management of dyslipidaemias:lipid modification to reduce cardiovascular risk. Eur Heart J 41:111-188, 2020

6) Hirsch AT, Haskal ZJ, Hertzer NR, et al;American Association for Vascular Surgery;Society for Vascular Surgery;Society for Cardiovascular Angiography and Interventions;Society for Vascular Medicine and Biology;Society of Interventional Radiology;ACC/AHA Task Force on Practice Guidelines;American Association of Cardiovascular and Pulmonary Rehabilitation;National Heart, Lung, and Blood Institute;Society for Vascular Nursing;TransAtlantic Inter-Society Consensus;Vascular Disease Foundation. ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease（lower extremity, renal, mesenteric, and abdominal aortic）:executive summary a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines（Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease）endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation;National Heart, Lung, and Blood Institute;Society for Vascular Nursing;TransAtlantic Inter-Society Consensus;and Vascular Disease Foundation. J Am Coll Cardiol 47:1239-1312, 2006

7) Diehm C, Allenberg JR, Pittrow D et al:Mortality and vascular morbidity in older adults with asymptomatic versus symptomatic peripheral artery disease. Circulation 120:2053-2061, 2009

8) Conte MS, Pomposelli FB, Clair DG, et al:Society for Vascular Surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities:management of asymptomatic disease and claudication. J Vasc Surg 61:2S-41S, 2015

9) Gerhard-Herman MD, Gornik HL, Barrett C, et al:2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease:Executive Summary:A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 135:e686-e725, 2017

10) Leng GC, Lee AJ, Fowkes FG, et al:Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population. Int J Epidemiol 25:1172-1181, 1996

11) Dormandy J, Belcher G, Broos P, et al:Prospective study of 713 below-knee amputations for ischaemia and the effect of a prostacyclin analogue on healing. Hawaii Study Group. Br J Surg 81:33-37, 1994

12) Takahara M, Iida O, Soga Y, et al:Absence of Preceding Intermittent Claudication and its Associated Clinical Freatures in Patients with Critical Limb Ischemia. J Atheroscler Thromb 22:718-725, 2015

13) Yasue H, Ogawa H, Tanaka H, et al:Effects of aspirin and trapidil on cardiovascular events after acute myocardial infarction. Japanese Antiplatelets Myocardial Infarction Study（JAMIS）Investigators. Am J Cardiol 83:1308-1313, 1999

14) Berger JS, Krantz MJ, Kittelson JM, et al:Aspirin for the prevention of cardiovascular events in patients with peripheral artery disease:a meta-analysis of randomized trials. JAMA 301:1909-1919, 2009

15) Gent M, Beaumont D, Blanchard J, et al:A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events（CAPRIE）. Lancet 348:1329-1339, 1996

16) Regensteiner JG, Ware JE, McCarthy WJ, et al:Effect of cilostazol on treadmill walking, community-based walking ability, and health-related quality of life in patients with intermittent claudication due to peripheral arterial disease:meta-analysis of six randomized controlled trials. J Am Geriatr Soc 50:1939-1946, 2002

17) Bedenis R, Stewart M, Cleanthis M, et al:Cilostazol for intermittent claudication. Cochrane Database Syst Rev 10:CD003748, 2014

18) Hiatt WR, Money SR, Brass EP:Long-term safety of cilostazol in patients with peripheral artery disease:The CASTLE study. J Vasc Surg 47:330-336, 2008

19) Miyashita Y, Saito S, Miyamoto A, et al:Cilostazol increases skin perfusion pressure in severely ischemic limbs. Angiology 62:15-17, 2011

20) Bonaca M, Bauersachs RM, Anand SS, et al:Rivaroxaban in Peripheral Artery Disease after Revascularization. NEJM 382:1994-204, 2020

21) Tepe G, Bantleon R, Brechtel K, et al:Management of peripheral arterial interventions with mono or dual antiplatelet therapydthe MIRROR study:a randomised and double-blinded clinicaltrial. Eur Radiol 22:1998-2006, 2012

22) Katsanos K, Spiliopoulos S, Saha P, et al:Comparative efficacy and safety of different antiplatelet agents for prevention of major cardiovascular events and leg amputations in patients with peripheral arterial disease:a systematic review and network meta-analysis. PLoS One 10:e0135692, 2015

23) Iida O, Yokoi H, Soga Y, et al:Cilostazol reduces angiographic restenosis after endovascular therapy for femoropopliteal lesions in the sufficient treatment of peripheral intervention by cilostazol study. Circulation 127:2307-2315, 2013

24) Bedenis R, Lethaby A, Maxwell H, et al:Antiplatelet agents for preventing thrombosis after peripheral arterial bypass surgery. Cochrane Database Syst Rev 2:CD000535, 2015

25) Dutch Bypass Oral anticoagulants or Aspirin（BOA）Study Group:Efficacy of oral anticoagulants compared with aspirin after infrainguinal bypass surgery（The Dutch Bypass Oral Anticoagulants or Aspirin Study）:a randomized trial. Lancet 355:346-351, 2000

26) Johnson WC, Williford WO:Benefits, morbidity, and mortality associated with long-term administration of oral anticoagulant therapy to patients with peripheral arterial bypass procedures:a prospective randomized study. J Vasc Surg 35:413-421, 2002

27) Monaco M, Di Tommaso L, Pinna GB, et al:Combination therapy with warfarin plus clopidogrel improves outcomes in femoropopliteal bypass surgery patients. J Vasc Surg 56:96-105, 2012

28) Belch JJ, Dormandy J:CASPAR Writing Committee Results of the randomized, placebo-controlled clopidogrel and acetylsalicylic acid in bypass surgery for peripheral arterial disease（CASPAR）trial. J Vasc Surg 52:825-833, 2010

29) Hiatt WR, Fowkes FG, Heizer G, et al:Ticagrelor versus Clopidogrel in Symptomatic Peripheral Artery Disease. N Engl J Med 376:32-40, 2017

30) Anand SS, Caron F, Eikelboom JW, et al:Major Adverse Limb Events and Mortality in Patients With Peripheral Artery Disease:The COMPASS Trial. J Am Coll Cardiol 71:2306-2315, 2018

31) Narula N, Dannenberg AJ, Olin JW, et al:Pathology of Peripheral Artery Disease in Patients With Critical Limb Ischemia. J Am Coll Cardiol 72:2152-2163, 2018