Medical therapy

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Medical therapy serves two goals in upper extremity arterial disease:

1. **Reduce systemic cardiovascular risk** (MI,(myocardial infarction (MI), stroke, cardiovascular death)
2. **Reduce limb events** and maintain patency after revascularization

[@esc2017] [@hiatt2015]

**Baseline therapy for atherosclerotic upper extremity disease**

- **Antiplatelet therapy:** single antiplatelet therapy is standard for symptomatic atherosclerotic disease. Clopidogrel demonstrated benefit over aspirin in atherosclerotic vascular disease populations (including peripheral arterial disease (PAD) subgroups). [@caprie1996]
- **High-intensity statin therapy:** reduces major cardiovascular events in high-risk atherosclerotic populations. [@hps2002]
- **Smoking cessation:** associated with improved outcomes and reduced mortality in symptomatic PAD populations (extrapolated to systemic atherosclerosis management). [@armstrong2014]
- Intensively manage BP,blood pressure (BP), diabetes, and lifestyle according to general vascular prevention standards. [@esc2017]

**Antithrombotic therapy after subclavian/innominate stenting (pragmatic approach)**

Evidence for DAPTdual antiplatelet therapy (DAPT) duration in subclavian stenting is limited; practice is typically extrapolated from peripheral and carotid stenting experience.

- **DAPT (aspirin + clopidogrel) for 1-3 months**, then **single antiplatelet therapy** long term, individualized by bleeding risk and competing indications (e.g., atrial fibrillation). [@esc2017]
- Consider **dual-pathway inhibition** (low-dose rivaroxaban plus aspirin) in selected patients with polyvascular atherosclerosis and acceptable bleeding risk; this strategy reduced cardiovascular and limb events in PAD populations and may be considered after non-coronary peripheral interventions on an individualized basis. [@eikelboom2017] [@voyager2020]

**Lipid intensification for very high-risk disease**

In very high-risk atherosclerotic disease with persistent LDLlow-density lipoprotein (LDL) elevation despite statin therapy, consider additional lipid-lowering therapy based on cardiovascular outcome trials. [@fourier2017] [@odyssey2018] Additionally, lipoprotein(a) (Lp(a)) should be measured at least once in a lifetime to identify patients at high risk for atherosclerotic cardiovascular disease (ASCVD). [@yang2026]

**Embolic disease**

For suspected acute arterial embolism, initiate systemic anticoagulation unless contraindicated while definitive source evaluation proceeds. [@white2006]