Thromboelastography With Platelet Mapping-Guided Thromboprophylaxis in Patients with Diabetes Undergoing Infrainguinal Endovascular Revascularization.

OBJECTIVE: Patients with diabetes represent one of the largest subgroups undergoing endovascular revascularization for peripheral artery disease (PAD) and remain at high risk for thrombosis and restenosis. Postprocedural antithrombotic management varies in practice and does not routinely measure platelet response. We evaluated whether thromboelastography with platelet mapping (TEG-PM)-guided thromboprophylaxis was associated with reduced target-vessel thrombosis or clinically significant stenosis. METHODS: We performed a prospective, single-center, sequential cohort study of patients (≥60 years) with diabetes undergoing infrainguinal endovascular revascularization for PAD. In the standard-of-care (SOC) cohort, postoperative thromboprophylaxis was determined by the treating surgeon. In the TEG-PM-guided cohort, serial postoperative TEG-PM measurements informed antiplatelet adjustment to meet prespecified platelet inhibition thresholds (30-86%). The primary outcome was target-vessel thrombosis or clinically significant stenosis at 12 months. RESULTS: Of 164 patients with diabetes, 62 received TEG-PM-guided thromboprophylaxis and 102 received SOC. At 12 months, target-vessel thrombosis or clinically significant stenosis was lower with TEG-PM-guided therapy than SOC (9.7% vs 25.5%; p=0.013). TEG-PM-guided therapy was associated with lower unadjusted hazard of this outcome (HR 0.34; 95% CI 0.14-0.84; p=0.019), although this was not significant after adjustment (HR 0.48; 95% CI 0.19-1.24; p=0.131). Major amputation, all-cause mortality, amputation-free survival, and clinically relevant non-major bleeding did not differ significantly at 12 months. No major bleeding occurred. CONCLUSIONS: TEG-PM-guided thromboprophylaxis was associated with a lower 12-month rate of target-vessel thrombosis or clinically significant stenosis without major bleeding, although this association was attenuated after multivariable adjustment. Future studies should determine whether TEG-PM-guided antiplatelet therapy adjustment improves target-vessel outcomes in patients with diabetes.