Peripheral artery disease (PAD) affects millions of Americans and remains a leading cause of disability, repeat hospitalizations, and limb loss. Advances in endovascular devices, surgical techniques, and medical therapies have dramatically improved our ability to restore blood flow to the legs. Yet despite this progress, one challenge continues to limit long-term success: what happens after the procedure.
Following lower extremity revascularization, most patients are prescribed blood thinners to help prevent clot formation and keep arteries or bypass grafts open. These medications are a cornerstone of vascular care, but the way we prescribe has changed remarkably little over time. As medicine becomes increasingly personalized, it is time to rethink whether a one-size-fits-all approach is still the best path forward.
Where current treatments fall short
Current treatment guidelines are based on large clinical trials and have helped establish effective standards of care. However, these recommendations are designed around population-level data rather than the biology of individual patients.
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We know that patients respond differently to antithrombotic medications. Some remain at high risk of developing thrombosis despite receiving guideline-directed therapy, leading to restenosis, repeat interventions, or even major amputation. Others may receive more aggressive therapy than necessary, increasing their risk of bleeding complications.
The challenge is that we often have no objective way of knowing which patients fall into either category. In many respects, we are still prescribing blood thinners based on what works for the average patient rather than understanding how each individual patient’s platelets respond to treatment.
Using this approach made sense when more personalized tools weren’t available. Today, it’s time to reconsider our approach.
Bringing precision medicine into vascular surgery
Across medicine, precision medicine is transforming how clinicians approach treatment decisions. Oncology has demonstrated the power of tailoring therapy to a patient’s unique biology, while cardiology and other specialties are increasingly adopting more individualized approaches.
Vascular surgery is poised to follow a similar path.
Emerging technologies, including thromboelastography with platelet mapping, allow physicians to evaluate how a patient’s platelets respond to antithrombotic medications. Rather than assuming every patient will respond similarly, these tools provide objective information about clotting function that can help guide personalized treatment decisions.
Instead of relying solely on population averages, clinicians can now better understand the patient sitting in front of them. That shift represents an important step toward more personalized, data-driven vascular care.
What personalized therapy could mean for patients
Our research, recently presented at the Society for Vascular Surgery’s Vascular Annual Meeting, demonstrated just how much platelet function can vary between patients receiving the same medications after lower extremity revascularization. By identifying patients with inadequate platelet inhibition and personalizing their antithrombotic therapy, we observed significantly lower rates of thrombosis and clinically significant restenosis, along with improvements in amputation-free survival, without an increase in major bleeding.
A more personalized approach allows clinicians to identify patients who remain at elevated thrombotic risk before complications occur. Rather than reacting after a bypass or stent has already failed, clinicians may be able to intervene earlier and optimize therapy based on an individual’s unique biology.
Moving from innovation to standard practice
While the research is promising, personalized coagulation profiling is not yet ready to become routine practice everywhere. The next step is validation through larger, multicenter randomized clinical trials to confirm that individualized treatment strategies consistently improve outcomes across diverse patient populations. Broader adoption will also require greater familiarity with platelet function testing, thoughtful integration into clinical workflows, and continued evidence demonstrating cost-effectiveness.
While these are important areas to address, these represent practical challenges rather than scientific barriers. Technology already exists, and the growing body of evidence suggests that individualized antithrombotic therapy deserves serious consideration as the next evolution in vascular care.
Looking ahead
The future of vascular patient care is not centered around prescribing more medication or performing more procedures. It is about delivering the right therapy to the right patient at the right time. As precision medicine continues to gain momentum, individualized antithrombotic therapy offers the potential to improve limb salvage, reduce complications, and fundamentally reshape how we care for patients living with peripheral artery disease.
About the author
Dr. Dua is an associate professor of surgery at the Massachusetts General Hospital (MGH)/Harvard Medical School. She is the director of the peripheral artery disease center, associate director of the wound center, clinical director of research, and director of the sub-internship in vascular surgery. She is the past director of the vascular lab at the MGH. She developed and currently leads the Limb Evaluation and Amputation Program (LEAP) at the MGH. She also founded and runs the only comprehensive vascular surgery homeless clinic in the country at the MGH.
Anahita Dua is a vascular surgeon.
