*Review* **Antithrombotic Therapy in Peripheral Artery Disease: Current Evidence and Future Directions**

**Mario Enrico Canonico 1,2,\*, Raffaele Piccolo 2, Marisa Avvedimento 2,3, Attilio Leone 2, Salvatore Esposito 2, Anna Franzone 2, Giuseppe Giugliano 2, Giuseppe Gargiulo 2, Connie N. Hess 1, Scott D. Berkowitz 1, Judith Hsia 1, Plinio Cirillo 2, Giovanni Esposito <sup>2</sup> and Marc P. Bonaca <sup>1</sup>**

<sup>1</sup> CPC Clinical Research, Department of Medicine, University of Colorado, Aurora, CO 80045, USA

<sup>2</sup> Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy

<sup>3</sup> Quebec Heart and Lung Institute, Laval University, Quebec City, QC G1V0A6, Canada

**\*** Correspondence: marioenrico.canonico@cpcmed.org; Tel.: +1-(303)-860-9900

**Abstract:** Patients with peripheral artery disease (PAD) are at an increased risk of major adverse cardiovascular events, and those with disease in the lower extremities are at risk of major adverse limb events primarily driven by atherothrombosis. Traditionally, PAD refers to diseases of the arteries outside of the coronary circulation, including carotid, visceral and lower extremity peripheral artery disease, and the heterogeneity of PAD patients is represented by different atherothrombotic pathophysiology, clinical features and related antithrombotic strategies. The risk in this diverse population includes systemic risk of cardiovascular events as well as risk related to the diseased territory (e.g., artery to artery embolic stroke for patients with carotid disease, lower extremity artery to artery embolism and atherothrombosis in patients with lower extremity disease). Moreover, until the last decade, clinical data on antithrombotic management of PAD patients have been drawn from subanalyses of randomized clinical trials addressing patients affected by coronary artery disease. The high prevalence and related poor prognosis in PAD patients highlight the pivotal role of tailored antithrombotic therapy in patients affected by cerebrovascular, aortic and lower extremity peripheral artery disease. Thus, the proper assessment of thrombotic and hemorrhagic risk in patients with PAD represents a key clinical challenge that must be met to permit the optimal antithrombotic prescription for the various clinical settings in daily practice. The aim of this updated review is to analyze different features of atherothrombotic disease as well as current evidence of antithrombotic management in asymptomatic and secondary prevention in PAD patients according to each arterial bed.

**Keywords:** peripheral artery disease (PAD); antithrombotic therapy; dual pathway inhibition (DPI); major adverse cardiovascular events (MACE); major adverse limb events (MALE)
