IYSC12 - Analysis of Low-Dose Rivaroxaban Following Peripheral Vascular Intervention in the Post-VOYAGER Era: Prescription Patterns, Predictors, Outcomes, and Vascular Surgeons’ Insights

Thursday, June 11, 2026

4:25 PM - 4:30 PM ET

Location: Hynes CC, Third Level, Room 309

Submitting & Presenting Author(s)

Hassan Chamseddine, MD

Case Western Reserve University School of Medicine, University Hospitals, Harrington Heart and Vascular Institute, Cleveland, OH
Cleveland, Ohio

Co-Author(s)

Vikram S. Kashyap, MD

Corewell Health
Corwell Health
Mouhammad Halabi, MD

Division of Vascular Surgery
Henry Ford Hospital, Detroit, MI, Michigan
AS

Alexander Shepard, MD

Division of Vascular Surgery
Henry Ford Hospital, Detroit, MI
Detroit, Michigan
Mohamad Chahrour, MD

University of Iowa, Iowa City, IA
Iowa City, Iowa
JC

Jae S. Cho

Professor of Surgery
Case Western Reserve University School of Medicine, University Hospitals, Harrington Heart and Vascular Institute, Cleveland, OH
Cleveland Heights, Ohio
Cassius Iyad Ochoa Chaar, MD, MS

Associate Professor of Surgery
Yale University School of Medicine
New Haven, Connecticut
HG

Heather Gornik

Case Western Reserve University School of Medicine, University Hospitals, Harrington Heart and Vascular Institute, Cleveland, OH
MS

Mehdi H. Shishehbor

Case Western Reserve University School of Medicine, University Hospitals, Harrington Heart and Vascular Institute, Cleveland, OH
HA

Herbert Aronow

Henry Ford Hospital, Detroit, MI
FC

Fatimah Chamseddine

University of Michigan, Ann Arbor, MI
JC

Jane Chung

Vascular surgery fellow
Case Western Reserve University School of Medicine, University Hospitals, Harrington Heart and Vascular Institute, Cleveland, OH
Cleveland, Ohio
AP

Avkash Patel

Vascular Resident
Case Western Reserve University School of Medicine, University Hospitals, Harrington Heart and Vascular Institute, Cleveland, OH
Cleveland, Ohio

Senior Author(s)

Loay S. Kabbani, MD, MHA (he/him/his)

Division of Vascular Surgery
Henry Ford Hospital, Detroit, MI
Detroit, Michigan

Objectives: Contemporary guidelines endorse dual pathway inhibition (DPI) with low-dose rivaroxaban plus antiplatelet therapy in patients with peripheral artery disease (PAD) undergoing lower extremity peripheral vascular intervention (PVI). However, national adoption patterns and real-world outcomes of DPI after PVI remain poorly characterized.

Methods: Patient with PAD undergoing PVI between January 2024 and December 2025 were identified in the Vascular Quality Initiative. Patients on pre- or post-operative full-dose anticoagulation were excluded. Discharge antithrombotic regimens were categorized as single antiplatelet therapy (SAPT), dual antiplatelet therapy (DAPT), or dual pathway inhibition (DPI) defined as a single antiplatelet agent combined with low-dose rivaroxaban (2.5mg twice daily). Multivariable logistic regression was used to identify factors independently associated with DPI initiation. Cox-regression was used to evaluate the long-term outcomes of reintervention and amputation-free survival. In parallel, an anonymous survey was distributed to a statewide vascular surgery society to assess perceptions regarding the clinical benefit of DPI.

Results: Among 60,601 patients undergoing PVI during the study period, 21% were discharged on SAPT, 72% on DAPT, and 7% on DPI. DPI utilization varied substantially across geographical regions (range: 4%-17%) and individual centers (range: 0%-51%). Significant predictors of DPI initiation included prior lower extremity revascularization (OR 2.55 [2.37-2.73], p< 0.001), multi-vessel treatment (OR 1.43 [1.21-1.70], p< 0.001), infra-popliteal intervention (OR 1.28 [1.15-1.42], p< 0.001), TASC C/D lesions (OR 1.59 [1.36-1.87], p< 0.001), and in-hospital target vessel thrombosis (OR 3.20 [2.28-4.48], p< 0.001) (Figure 1). In contrast, lower socioeconomic status was associated with a 20% reduction in the odds of DPI initiation (OR 0.81 [0.73-0.90], p< 0.001). At 18-month follow-up, no difference in reintervention (HR 1.33 [0.98-1.80], p=0.066), amputation (HR 1.22 [0.75-1.98], p=0.424), or amputation-free survival (HR 1.15 [0.94-1.41], p=0.170) was observed with DPI compared to SAPT or DAPT (Figure 2). Eighty percent of vascular surgeons reported uncertainty regarding the clinical benefit of DPI, with the majority (88%) expressing interest in a randomized controlled trial comparing DAPT with DPI and 92% indicating willingness to enroll patients in such trial.

Conclusions: Although endorsed by contemporary guidelines, DPI after PVI is infrequently and variably used, primarily in patients with advanced disease complexity. In this national cohort, DPI was not associated with a measurable reduction in amputation or reintervention. Persistent surgeon uncertainty and broad willingness to enroll patients in a randomized trial suggest that current practice may reflect true clinical equipoise rather than simple failure to adopt guideline recommendations.