According to Jeon JW and colleagues, patients after arteriovenous fistula surgery with cilostazol use developed fewer vascular complications than those without cilostazol use.1 This result suggested the potential benefit of cilostazol use in patients with arteriovenous fistula. However, there seem several issues to consider in this study: an indication for cilostazol and an evaluation for drug-induced adverse events.

First, cilostazol is indicated for intermittent claudication (secondary to peripheral artery disease) only. Although cilostazol is sometimes used for secondary prevention of non-cardioembolic stroke or transient ischemic attack, these are off-label use. It is essential to clarify the indication of cilostazol in this study, and ethical validity seems warranted in this situation. Second, some patients in the cilostazol group had coronary artery disease, heart failure, or atrial fibrillation/flutter. Phosphodiesterase inhibitors have demonstrated decreased survival compared with placebo in patients with class III to IV heart failure and those with ischemic heart disease.2 Thus, cilostazol is generally contraindicated for these populations. Besides, cilostazol may also induce tachycardia and hypotension. Caution is necessary when prescribing cilostazol to individuals with arterial fibrillation/flutter.3 Lastly, the outcomes in this study did not include the adverse events during the observation period. This study included patients over 65 years of age and those using antiplatelet or anticoagulant agents. These populations were at high risk of bleeding events,4 and the occurrence of bleeding events and mortalities should have been evaluated.

Although cilostazol seems a promising agent, it is unclear whether cilostazol can be used safely in patients after arteriovenous fistula surgery who often have cardiovascular diseases. Further reports should be accumulated to understand the safety profile of cilostazol in this situation.