Poor glycemic control is independently associated with fibrinolysis shutdown in patients with peripheral artery disease.

Objective: Fibrinolysis plays a critical role in regulating thrombotic potential by facilitating the breakdown of fibrin-rich thrombi after clot formation. Impaired fibrinolysis, often referred to as hypofibrinolysis or fibrinolytic shutdown, results in reduced clot degradation and promotes thrombus persistence, propagation, and recurrent vascular occlusion. Consequently, impaired fibrinolysis is increasingly recognized as an important contributor to thrombotic risk in patients with peripheral artery disease (PAD). Poor glycemic control has been associated with a prothrombotic milieu through mechanisms including enhanced platelet activation, increased fibrin clot density, and reduced fibrinolytic capacity; however, its relationship with fibrinolytic shutdown in PAD remains poorly defined. Therefore, we aimed to evaluate the association between glycemic control and fibrinolytic shutdown using viscoelastic testing. Methods: We performed a retrospective cohort study of 192 patients with PAD who underwent revascularization. Patients were stratified by glycated hemoglobin (HbA1c) < 7% and ≥7%. Viscoelastic testing was performed using thromboelastography. Fibrinolysis was assessed using lysis at 30 minutes, and phenotypes were defined as severe shutdown (≤0.3%), partial shutdown (0.3%-0.8%), physiologic (0.8%-3.0%), and hyperfibrinolysis (>3.0%). Multivariable logistic regression evaluated the association between HbA1c and severe fibrinolysis shutdown, adjusting for demographic, clinical, and treatment variables. Results: Patients with HbA1c ≥ 7% demonstrated lower lysis at 30 minutes values compared with those with HbA1c < 7% (median, 0.00 [interquartile range, 0.00-0.35] vs median, 0.30 [interquartile range, 0.00-0.90]; Conclusions: Poor glycemic control was independently associated with severe fibrinolysis shutdown in patients with PAD, and severe shutdown was associated with increased thrombosis-driven reintervention. A dose-dependent relationship between HbA1c and impaired fibrinolysis suggests a mechanistic link between hyperglycemia and prothrombotic risk. Hence, patients with higher glucose levels may need increased thromboprophylaxis strategies to mitigate thrombotic risk. These findings may have implications for risk stratification and targeted therapeutic strategies. Clinical relevance: Fibrinolysis shutdown is an underrecognized contributor to residual thrombotic risk in peripheral artery disease (PAD), yet it is not captured by conventional risk assessment tools. This study demonstrates that poor glycemic control (glycated hemoglobin ≥ 7%) is independently and dose-dependently associated with severe fibrinolysis shutdown on thromboelastography in patients with PAD. These findings suggest that hyperglycemia contributes to a prothrombotic hemostatic phenotype distinct from platelet-mediated pathways targeted by standard antiplatelet therapy. Viscoelastic testing may therefore identify a subset of patients with PAD, particularly those with suboptimal glycemic control who could benefit from closer surveillance, metabolic optimization, or individualized antithrombotic strategies to reduce thrombotic complications and adverse limb events.