Advancements in Perioperative Antithrombotic Management: Tailored Strategies and Platelet Function Assessment in Atherosclerotic Vascular Disease

This thesis investigates a key challenge in contemporary vascular medicine: optimising individualised antithrombotic management for patients with peripheral arterial disease (PAD) and carotid stenosis (CS). The primary conclusion is that current clinical practice is marked by a persistent tension between guideline recommendations derived from population-level data and the biological and procedural heterogeneity inherent in individual patients. Although antiplatelet therapy remains a key component of secondary prevention and perioperative risk mitigation, its implementation in clinical practice is often inconsistent. Moreover, the evidence base informing decisions about treatment intensity, duration, and monitoring remains incomplete, especially in the contexts of PAD and CS.
A key contribution of this thesis is to elucidate that suboptimal prescribing practices and considerable treatment variation are not incidental but represent inherent structural characteristics of contemporary clinical practice. This bears significant clinical implications, as undertreatment and inconsistency are likely to increase the incidence of preventable thrombotic events, whereas overtreatment may elevate bleeding risk without commensurate benefit. Consequently, the thesis proposes that future advancements in antithrombotic therapy should not merely target increased or intensified treatment, but should prioritise the optimisation of patient-specific treatment selection. Delivering the appropriate intervention to the right patient, at the optimal time, and within the correct setting.
Within this framework, the thesis critically evaluates platelet function testing (PFT) and pharmacogenetic approaches as prospective tools for precision medicine. The discussion underscores that these technologies are biologically plausible and clinically appealing; however, their integration into routine clinical practice is hindered by methodological and practical constraints. Factors such as assay-dependent variability, uncertain cutoff thresholds, perioperative fluctuations in platelet reactivity, and limited concordance across tests complicate interpretation at the individual level. Consequently, the thesis argues for a cautious, hypothesis-driven deployment of PFT, reserved for select high-risk scenarios in which significant thrombotic and hemorrhagic risks entail complex therapeutic decisions.
The broader implication is that precision antithrombotic therapy in vascular pathology will require a comprehensive, multifaceted approach rather than dependence on singular biomarker modalities or isolated diagnostic assays. Future advancements are anticipated to hinge upon the integration of detailed clinical phenotyping, alongside procedural parameters, longitudinal real-world outcome datasets, platelet reactivity assays, and pharmacogenomic profiling, all synthesised into validated, clinically actionable decision algorithms. Within this framework, the position advocates initiating prospective, randomised controlled trials tailored to PAD and CS, alongside the development of standardised diagnostic workflows and efficacy assessments.
In conclusion, this thesis recommends developing a translational roadmap to advance personalised antithrombotic strategies in vascular surgery and vascular medicine. It systematically delineates evidence-practice gaps, highlights the potential and limitations of current precision medicine tools, and contends that substantial progress requires generating disease-specific evidence, standardising assays, and robust multidisciplinary collaboration. The future perspective is therefore not simply intensified antithrombotic therapy, but the development of a more precise, context-sensitive, and patient-centred paradigm for thrombotic risk assessment and management.