Continuation Of Aspirin Research Articles

Preoperative aspirin continuation versus replacement therapy with low molecular weight heparin before coronary surgery: effects on postoperative bleeding risk

Management of preoperative antiplatelet therapy in coronary surgery is still variable among surgeons. Guidelines collide with prejudices: replacement of aspirin with low molecular weight heparin (LMWH) is still performed in many Centers due to a presumed minor risk of intraoperative bleeding, even though supporting evidences are weak and detrimental effects are well-described.

Abstract 12267: Clinical Significance of Very Late Ischemic and Bleeding Events After Percutaneous Coronary Intervention

Background: Ischemic and bleeding events following percutaneous coronary intervention are associated with increased mortality, but the prognosis of events occurring beyond 1 year is unknown. Methods: The Dual Antiplatelet Therapy study randomized 11,648 subjects following percutaneous coronary intervention who completed 12 months of dual antiplatelet therapy to either continued thienopyridine plus aspirin treatment for another 18 months versus aspirin therapy alone. Subjects were followed for 21 months after randomization. Ischemic events were defined as Academic Research Consortium definite or probable stent thrombosis, myocardial infarction, ischemic stroke and other cardiovascular deaths. Bleeding events were defined by GUSTO classification (moderate or severe). Kaplan-Meier methods were used to estimate the cumulative incidence of death (regardless of cause) following ischemic and bleeding events over the full study follow-up. Results: At 21 months after randomization, 566 (4.9%) patients had ischemic events and 232 (2.0%) patients had bleeding events. Of the ischemic events, 58.8% were myocardial infarctions, 16.4% were stent thromboses and 12.8% were other cardiovascular deaths. Of all myocardial infarctions and stent thromboses, 8 (2.0%) were fatal on presentation. Among bleeding events, 66.0% were moderate and 34.0% were severe. Of all bleeding events, 3 (1.3%) were immediately fatal. In patients with ischemic events, 24.7% died, and the cumulative incidence of death preceded by an ischemic event was greater following myocardial infarction (0.39%) compared with stent thrombosis (0.13%) and ischemic stroke (0.11%). Among patients with a bleed, 17.7% died, and the cumulative incidence of death preceded by a bleed was 0.14% after a moderate bleed and 0.24% after a severe bleed (see Figure). Conclusions: Very late ischemic and bleeding events were infrequent, but patients who suffered these events are subject to high mortality risk.

What is the optimal perioperative management of antiplatelet therapy?

What is the optimal perioperative management of antiplatelet therapy?

Outcomes of Laparoscopic Partial Nephrectomy in Patients Continuing Aspirin Therapy

A clinical dilemma surrounds the use of aspirin therapy during laparoscopic partial nephrectomy. Despite reduced cardiac morbidity with perioperative aspirin use, fear of bleeding related complications often prompts discontinuation of therapy before surgery. We evaluate perioperative outcomes among patients continuing aspirin and those in whom treatment is stopped preoperatively. A total of 430 consecutive cases of laparoscopic partial nephrectomy performed between January 2012 and October 2014 were reviewed. Patients on chronic aspirin therapy were stratified into on aspirin and off aspirin groups based on perioperative status of aspirin use. Primary end points evaluated included estimated intraoperative blood loss and incidence of bleeding related complications, major postoperative complications, and thromboembolic events. Secondary outcomes included operative time, transfusion rate, length of hospital stay, rehospitalization rate and surgical margin status. Among 101 (23.4%) patients on chronic aspirin therapy, antiplatelet treatment was continued in 17 (16.8%). Bleeding developed in 1 patient in the on aspirin group postoperatively and required angioembolization. Conversely 1 myocardial infarction was observed in the off aspirin cohort. There was no significant difference in the incidence of major postoperative complications, intraoperative blood loss, transfusion rate, length of hospital stay and rehospitalization rate. Operative time was increased with continued aspirin use (181 vs 136 minutes, p=0.01). Laparoscopic partial nephrectomy is safe and effective in patients on chronic antiplatelet therapy who require perioperative aspirin for cardioprotection. Larger, prospective studies are necessary to discern the true cardiovascular benefit derived from continued aspirin therapy as well as better characterize associated bleeding risk.

New therapy in cardioprotection.

An increasing number of patients are presenting for major surgery with cardiovascular comorbidities. Evidence of myocardial injury was found in 8% of all noncardiac surgery patients older than 45 years and was associated with adverse outcome. For this reason, there has been a lot of interest in finding and evaluating effective cardioprotective interventions. Current evidence suggests that statins, volatile anesthetic agents, and propofol are cardioprotective. Beta blockers reduce myocardial injury, but the resultant hypotension may contribute to the increased all-cause mortality and stroke risk seen. Likewise, alpha 2 agonists can be a cause of cardiac injury if hypotension is not promptly managed. Continuation of aspirin perioperatively can increase the risk of major bleeding with or without the benefit of reduced myocardial risk. Contrary to the initial Evaluation of Nitrous Oxide in the Gas Mixture for Anaesthesia study, nitrous oxide does not seem to increase the risk of myocardial injury. It is recommended that patients already on statins or beta blockers should have them continued perioperatively. If beta blockers are initiated, the dose should be titrated to heart rate and blood pressure. The decision regarding continuation of aspirin should be on a case-to-case basis based on patient and surgical risk factors.

Are the current recommendations for the use of aspirin in primary prevention of cardiovascular disease applicable in low-income countries?

Although evidence has accumulated that long-term aspirin therapy is beneficial in secondary prevention of cardiovascular disease (CVD), a lot of controversies persist regarding the benefit of aspirin use in primary prevention of CVD. In low-income countries (LIC) specifically, the decision to prescribe aspirin for primary CVD prevention is more problematic, as there is a dearth of evidence in this regard. Aspirin has been shown to have relative beneficial effects in preventing a first myocardial infarction, but not stroke. However, as stroke is the prevailing CVD in many LIC, especially in Africa, the benefit of aspirin in these settings is therefore questionable. Indeed, there is no published trial that has evaluated the benefits and risks of continuous aspirin therapy in populations of LIC. Furthermore, though cardiovascular risk assessment is crucial in decision-making for the use of aspirin in primary prevention of CVD, there are no risk assessment tools that have been validated in African populations. Studies are urgently warranted, to determine the usefulness of aspirin in primary prevention of CVD in low-income settings where the drug is highly available and affordable, as CVD is becoming the leading cause of deaths in LIC.

Persistence with secondary prevention medications after acute myocardial infarction: Insights from the TRANSLATE-ACS study

Persistent use of secondary prevention therapies after acute myocardial infarction (MI) is critical to optimizing long-term outcomes. Medication persistence was assessed among 7,955 MI patients in 216 hospitals participating in the Treatment with Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome study from 2010 to 2012. Persistence was defined as continuation of aspirin, adenosine diphosphate receptor inhibitors, β-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and statins from discharge to 6 months post-MI. Multivariable logistic regression modeling was used to determine factors associated with nonpersistence, defined as <80% persistence with all medication classes. Overall, 31% of MI patients stopped taking a least 1 medication by 6 months. The most common reasons cited for medications discontinuation were side effects and physician instruction (57%), whereas financial concerns were cited in 8% overall. After multivariable modeling, black race (odds ratio 1.36, 95% CI 1.15-1.62), older age (odds ratio 1.07, 95% CI 1.02-1.12), atrial fibrillation (odds ratio 1.67, 95% CI 1.33-2.09), dialysis (odds ratio 1.79, 95% CI 1.15-2.78), and depression (odds ratio 1.22, 95% CI 1.02-1.45) were associated with lower likelihood of persistence. Private insurance (odds ratio 0.85, 95% 0.76-0.95), prescription cost assistance (odds ratio 0.63, 95% CI 0.54-0.75), and outpatient follow-up arranged before discharge (odds ratio 0.89, 95% CI 0.80-0.99) were associated with higher persistence. Nearly one-third of MI patients are no longer persistent with their prescribed medications by 6 months. Patients at high risk for nonpersistence may be identified by clinical and sociodemographic features. These observations underscore key opportunities to optimize longitudinal use of secondary prevention therapies.

An observational study investigating the effect of platelet function on outcome after colorectal surgery

IntroductionPrevious studies have assumed patients have uniform responses to aspirin, yet significant numbers are occult hypo- or hyper-responders. A new validated test of platelet function measures platelet P-selectin expression, which rises with increased platelet activity. This study investigated the measured perioperative changes in platelet function in response to aspirin, and subsequently whether quantitative variations in platelet activity affected perioperative complication severity and frequency. Methods107 patients undergoing major colorectal surgery were recruited and assigned to either control (no antiplatelet therapy) or aspirin groups. P-selectin was measured following platelet stimulation at recruitment prior to cessation of medication, and at surgery before intervention. Perioperative complications, hemoglobin changes and blood transfusions were also recorded. ResultsPlatelet function was higher in control (n = 87) than aspirin group (n = 20) at recruitment (median 1303u [IQR 1102–1499] vs 77u [IQR 63.5–113.5],P < 0.01) and surgery (median 1224u [IQR 944–1496] vs 281.5u [IQR 106.8–943], P < 0.01). There was a positive correlation between length of aspirin cessation and platelet function at surgery (RS = 0.66, P < 0.01). Complication rates and hemorrhagic complication rates (P < 0.05) were higher with aspirin than control, although complication severity was not increased. Platelet function of the entire cohort at surgery was not associated with complication rate, severity or transfusion use. DiscussionAlthough complication rates were higher in aspirin group, impaired platelet function within ranges seen with aspirin continuation did not affect complication severity or rate or blood transfusion use. Consequently, aspirin continuation may not affect clinical outcome in patients undergoing major colorectal surgery and requires further investigation with a large randomized trial.

Update on aspirin desensitization for chronic rhinosinusitis with polyps in aspirin-exacerbated respiratory disease (AERD).

Aspirin-exacerbated respiratory disease (AERD) is a clinical condition which results in adverse upper and lower respiratory symptoms, particularly rhinitis, conjunctivitis, bronchospasm, and/or laryngospasm, following exposure to cyclooxygenase-1 (COX-1) inhibiting drugs, namely aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs). A provocative aspirin challenge is the gold standard for diagnosis of AERD. Aspirin desensitization and continuous aspirin therapy has been highly efficacious in those patients with suboptimal control of their disease on current available pharmacotherapy or those with other underlying conditions (i.e., cardiovascular disease) who may require frequent treatment with aspirin or NSAIDs. This review article focuses on aspirin desensitization and the management of patients with AERD with a particular emphasis on outcomes in those patients with chronic rhinosinusitis and nasal polyposis.

Thienopyridine derivatives as risk factors for bleeding following high risk endoscopic treatments: Safe Treatment on Antiplatelets (STRAP) study.

The optimal method of perioperative management of antiplatelet agents during endoscopic procedures that carry a high risk of bleeding is still controversial. The aim of this study was to evaluate the safety of continuing aspirin treatment during these procedures in an Asian population. A multicenter, prospective, observational cohort study was conducted at six high volume endoscopy centers in Japan. The study included patients at high risk of thromboembolism who were regularly taking antiplatelet agents (e. g. thienopyridine derivatives and aspirin). Enrolled patients continued their aspirin therapy, and underwent endoscopic procedures that had a high risk of bleeding for treatment of lesions in the upper and lower gastrointestinal tracts. The primary end point was the rate of major bleeding complications after endoscopic procedures. The study was terminated in accordance with predetermined safety criteria because 7 of 28 consecutive patients experienced major bleeding complications (25.0 %; 95 % confidence interval 10.7 % - 44.9 %). All major bleeding complications occurred following endoscopic submucosal dissection (ESD; 6 stomach, 1 colon). Univariate analysis showed that postoperative administration of thienopyridine derivatives was the only significant factor associated with postoperative bleeding (P = 0.01). Subanalysis of gastric ESD (23 lesions in 19 patients) confirmed that the administration of thienopyridine derivatives (P = 0.01) and that of multiple agents (P = 0.02) were the significant factors. All bleeding complications (postoperative day 11.2 ± 3.5) occurred after resuming thienopyridine derivative therapy postoperatively (postoperative day 2.3 ± 2.4). In Asian patients taking thienopyridine derivatives with aspirin, cautious postoperative care is necessary for those undergoing endoscopic procedures that are associated with a high risk of bleeding, especially gastric ESD. Continuation of aspirin alone during these endoscopic procedures may be acceptable. UMIN000009176.

State of the Art: Medical treatment of aspirin exacerbated respiratory disease (AERD).

Aspirin exacerbated respiratory disease (AERD) is characterized as adult onset asthma, nasal polyps, chronic rhinosinusitis, and hypersensitivity to a cyclooxygenase-1 (COX-1) inhibitor, viz aspirin or nonsteroidal antiinflammatory drugs (NSAIDs). The method for diagnosing AERD is with aspirin challenge, and treatment includes aspirin desensitization followed by continued daily aspirin. Although oral challenge has been the mainstay in the United States, lysyl-aspirin has been validated as a diagnostic tool for aspirin-sensitive asthma and will be discussed further in this article. The challenges with aspirin therapy surrounding endoscopy and perioperative aspirin therapy will be discussed. Additionally, daily aspirin therapy is not for everyone. Aspirin is relatively contraindicated in those with a history of gastrointestinal bleed and an absolute contraindication in pregnancy. Aspirin desensitization and subsequent treatment has been shown to be highly effective for AERD.

Continuous aspirin use does not increase post-endoscopic dissection bleeding risk for gastric neoplasms in patients on antiplatelet therapy.

Background and study aims: Discontinuation of all antiplatelet agents before endoscopic procedures may cause serious complications in some patients. The aim of this study was to evaluate the hemorrhagic risk of post-endoscopic submucosal dissection (ESD) in patients on antiplatelet therapy (APT). Patients and methods: The subjects were 350 patients (377 lesions) who underwent gastric ESD between January 2007 and July 2013. The patients were categorized based on antiplatelet therapies. The primary outcome was post-ESD bleeding. Multivariate analysis was performed to identify independent risk factors for post-ESD bleeding. Results: The patients were categorized into three groups: (1) no APT, 261 patients with 281 lesions; (2) single APT, 58 patients with 63 lesions (53 patients with low dose aspirin [LDA] and 5 patients with a thienopyridine); and (3) dual APT (DAPT), 31 patients with 33 lesions (DAPT with LDA and a thienopyridine). Post-ESD bleeding occurred in 16 of 261 patients in the no APT group (6.1 %), 9 of 58 patients in the single APT group (15.5 %), and 11 of 31 patients in the DAPT group (35.5 %). In multivariate analysis with a Cox proportional hazards model in the no APT and single APT groups, APT (HR 2.7, 95 %CI 1.1 – 6.6, P = 0.03) and diameter of the resected specimen of 40 mm or greater (HR 2.7, 95 %CI 1.2 – 5.9, P = 0.01) were significant risk factors for post-ESD bleeding. In multivariate analysis in the no APT and DAPT groups, DAPT was the only significant risk factor for post-ESD bleeding (HR 16.3, 95 %CI 3.4 – 78.2, P < 0.01). Continuous LDA was not a significant risk factor for post-ESD bleeding in both analyses (HR 0.8, 95 %CI 0.2 – 3.6, P = 0.72 in the no APT and single APT groups; HR 1.0, 95 %CI 0.2 – 5.1, P = 0.95 in the no APT and DAPT groups). Conclusions: APT increased the risk for post-ESD bleeding, and DAPT markedly increased the risk for bleeding. Continuous LDA did not produce an additional hemorrhagic risk in all patients treated with APT. Thus, patients treated with APT should be careful monitored for post-ESD bleeding, and LDA should not be interrupted in patients with a high thromboembolic risk.

Risk factors for early and delayed post-operative bleeding after endoscopic submucosal dissection of gastric neoplasms, including patients with continued use of antithrombotic agents.

BackgroundEndoscopic submucosal dissection (ESD) has become widely accepted as a standard treatment for gastric epithelial neoplasms. Antithrombotic agents are widely used to prevent thromboembolic disease. However, the feasibility of endoscopic procedures for patients using such agents has been rarely investigated. The aim of this study was to identify risk factors for post-operative bleeding after gastric ESD and to evaluate the relationship between the use of antithrombotic agents and post-operative bleeding.MethodsFrom June 2005 to March 2014, 413 patients with 425 gastric neoplasms were treated by ESD. The demographic and clinical parameters associated with post-operative bleeding were investigated. 83 patients receiving antithrombotic agents were separately assessed using various methods of administration during the ESD procedure. Post-operative bleeding that occurred within 5 days of ESD was defined as early post-operative bleeding, whereas subsequent bleeding was defined as delayed bleeding.ResultsThe overall post-operative bleeding rate was 4.7%. In patients with continued low-dose aspirin (LDA), heparin replacement (HR), or continued LDA along with HR, post-operative bleeding rates were 9.5%, 23.8%, and 25.0%, respectively. On multivariate analysis, a specimen size of ≥40 mm was a risk factor for early post-operative bleeding [odds ratio (OR) 6.08, 95% CI: 1.74–21.27], and HR and chronic kidney disease (CKD) requiring hemodialysis were risk factors for delayed bleeding (OR 12.23, 95% CI: 2.63–56.77 and OR 28.35, 95% CI: 4.67–172.11, respectively). Continued LDA was not a risk factor for post-operative bleeding.ConclusionsLarge specimen size is a risk factor for early post-operative bleeding, and HR and CKD requiring hemodialysis are risk factors for delayed bleeding. Patients with risk factors should be carefully watched, allowing for the timing of post-operative bleeding after ESD.

Lack of evidence for increased postoperative bleeding risk for dental osteotomy with continued aspirin therapy.

Dental osteotomy, the removal of an impacted, ankylosed, or severely destroyed tooth requiring an osteotomy, is more invasive than other minor dental procedures and therefore also has a higher bleeding risk. A considerable number of patients under antiplatelet therapy interrupt their therapy perioperatively, which, however, increases the risk of thromboembolism. This retrospective study assessed postoperative bleeding incidence for a total of 297 dental osteotomies with continued aspirin therapy, compared with that of 179 similar procedures on patients who were not on any anticoagulation or anti-platelet therapy. All procedures were carried out on an outpatient basis. Postoperative bleeding event was rare in both groups, 5 (1.7%) and 2 (1.1%), respectively, and the difference was not significant (P= .7). Continued aspirin therapy in patients undergoing dental osteotomies has no effect on the incidence of postoperative bleeding and should not be interrupted.

Stent-assisted coiling of wide-necked intracranial aneurysms using the Solitaire AB stent

ABSTRACT Context: Stent-assisted coiling of wide-necked and complex intracranial aneurysms is an effective and feasible treatment option. The self-expanding, fully retrievable Solitaire AB (eV3, Irvine, CA, USA) stent is the latest neurovascular remodeling device available. To the best of our knowledge, there are no studies of Solitaire AB-assisted coiling of wide-necked intracranial aneurysms from India. Aim: Solitaire AB-assisted coiling of wide-necked intracranial aneurysms. Materials and Methods: The study was conducted in a tertiary care center with a dedicated Interventional Neurology division from 2009 to 2013. Consecutive patients with wide-necked aneurysms who underwent coiling assisted by the Solitaire AB stent were enrolled in the study. Axium 3D and Helix (eV3, Irvine, CA, USA) platinum coils were used to densely pack the aneurysm sac after deploying the stent across the neck. All patients were pretreated with antiplatelets according to protocol. Subsequently, dual antiplatelets were given for 6 months followed by continued aspirin. Outcome was assessed at 3 months using the modified Rankin Scale. Statistical Analysis Used: Statistical analysis was done using the SPSS 17.0 software. Results: A total of 16 patients underwent stent-assisted coiling. The most common site was the internal carotid artery (nine patients), median aneurysm size was 7 mm and median neck diameter was 5 mm. Thirteen patients presented with ruptured aneurysms. We achieved complete occlusion in all patients with no major complications. Thirteen patients were followed up, all have an mRS score of zero or one. Conclusion: We conclude that for wide-necked aneurysms, stent-assisted coiling using the Solitaire AB is a safe and effective treatment option.

Anticoagulation and Antiplatelet Therapy in Urological Practice: ICUD/AUA Review Paper

Given the lack of urology specific directives for the periprocedural management of anticoagulant and antiplatelet medications, the AUA (American Urological Association) and ICUD (International Consultation on Urological Disease) named an international multidisciplinary panel to develop consensus based recommendations. A systematic literature review was queried by a methodologist for 3 questions. 1) When and in whom can anticoagulant/antiplatelet prophylaxis be stopped in preparation for surgery? 2) What procedures can be safely performed without discontinuing anticoagulant/antiplatelet prophylaxis? 3) What periprocedural strategies can adequately balance the risk of major surgical bleeding vs the risk of major thrombotic event? Hematology and cardiology guidelines, and 79 articles were selected for full review. Multidisciplinary management of anticoagulant/antiplatelet medications for patients with recent thromboembolic events, mechanical cardiac valves, atrial fibrillation and cardiac stents would reduce the high morbidity and mortality of inexpertly discontinuing or modifying these lifesaving therapies. No elective procedures requiring interruption of dual antiplatelet therapies should be performed with a recent bare metal or drug eluting stent. The risk of significant bleeding complications is low for patients who require continuation of aspirin for ureteroscopy, transrectal prostate biopsies, laser prostate outlet procedures and percutaneous renal biopsy. Open extirpative prostate and renal procedures can be performed with a low risk of significant hemorrhage for patients on aspirin and those requiring heparin based bridging strategies. The current literature does not give direction on the timing of the resumption of anticoagulant/antiplatelet prophylaxis other than that it be resumed as soon as the risk of bleeding has decreased. A total of 2,674 nonredundant article abstracts were obtained and assessed for relevance to key questions outlined by the panel. Overall 106 articles were selected for full text review and accepted or rejected based on the relation to the topic, quality of information and key questions. A total of 79 articles were accepted. Reasons for rejection (27 articles) included abstract only (12), insufficient information or unrelated to topic (13) and redundancy (2). We extracted study design, patient population, followup period and results from accepted articles, which serve as the evidence base.

Risk factors for small-bowel mucosal breaks in chronic low-dose aspirin users: data from a prospective multicenter capsule endoscopy registry

To develop appropriate management strategies for patients who take low-dose aspirin, it is important to identify the risk factors for GI injury. However, few studies have described the risk factors for small-bowel injury in these patients. To investigate factors influencing the risk of small-bowel mucosal breaks in individuals taking continuous low-dose aspirin. Capsule endoscopy data were collected prospectively from 5 institutions. Yokohama City University Hospital and 4 other hospitals. A total of 205 patients receiving treatment with low-dose aspirin for over 3 months. Colonoscopic and upper GI endoscopy had been performed in all of the patients before the capsule endoscope evaluation. Risk factors for small-bowel mucosal breaks. Of the 198 patients (141 male; mean age 71.9 years) included in the final analysis, 114 (57.6%) had at least 1 mucosal break. Multivariate analysis identified protein pump inhibitor (PPI) use (OR 2.04; 95% confidence interval [CI], 1.05-3.97) and use of enteric-coated aspirin (OR 4.05; 95% CI, 1.49-11.0) as independent risk factors for the presence of mucosal breaks. Cross-sectional study. PPI use appears to increase the risk of small-bowel injury in patients who take continuous low-dose aspirin. Clinicians should be aware of this effect of PPIs; new strategies are needed to treat aspirin-induced gastroenteropathy.

Feasibility of aspirin continuation during the perioperative period for pulmonary resection in lung cancer patients: a retrospective study at a single institute in Japan

To evaluate the feasibility of aspirin continuation during the perioperative period for pulmonary resection in lung cancer patients. A retrospective study was conducted in 46 patients who were taking aspirin and underwent pulmonary resection. The indications for aspirin were generally a cardiovascular or cerebrovascular comorbidity. Whether to continue or discontinue aspirin was determined based on the severity of the cardiovascular or cerebrovascular comorbidity, along with the patient's overall condition. The intraoperative and postoperative outcomes were compared between patients continuing and those discontinuing aspirin. Twenty patients continued (group C) and 26 patients discontinued (group D) aspirin. The length of the operation (226 ± 97 min in group C vs. 189 ± 90 min in group D), intraoperative bleeding (234 ± 232 vs. 204 ± 367 g) and average pleural discharge on postoperative days 1, 2 and 3 (331, 230 and 215 vs. 304, 210 and 174 ml/day) showed no significant differences between the two groups. The postoperative complication rates were also not significantly different between the two groups [eight patients (40%) in group C vs. nine patients (35%) in group D]. Continuous administration of aspirin during the perioperative period for pulmonary resection in lung cancer patients appears to be clinically feasible in the Japanese population.

Stent-assisted coiling of wide-necked intracranial aneurysms using the Solitaire AB stent.

Context:Stent-assisted coiling of wide-necked and complex intracranial aneurysms is an effective and feasible treatment option. The self-expanding, fully retrievable Solitaire AB (eV3, Irvine, CA, USA) stent is the latest neurovascular remodeling device available. To the best of our knowledge, there are no studies of Solitaire AB-assisted coiling of wide-necked intracranial aneurysms from India.Aim:Solitaire AB-assisted coiling of wide-necked intracranial aneurysms.Materials and Methods:The study was conducted in a tertiary care center with a dedicated Interventional Neurology division from 2009 to 2013. Consecutive patients with wide-necked aneurysms who underwent coiling assisted by the Solitaire AB stent were enrolled in the study. Axium 3D and Helix (eV3, Irvine, CA, USA) platinum coils were used to densely pack the aneurysm sac after deploying the stent across the neck. All patients were pretreated with antiplatelets according to protocol. Subsequently, dual antiplatelets were given for 6 months followed by continued aspirin. Outcome was assessed at 3 months using the modified Rankin Scale.Statistical Analysis Used:Statistical analysis was done using the SPSS 17.0 software.Results:A total of 16 patients underwent stent-assisted coiling. The most common site was the internal carotid artery (nine patients), median aneurysm size was 7 mm and median neck diameter was 5 mm. Thirteen patients presented with ruptured aneurysms. We achieved complete occlusion in all patients with no major complications. Thirteen patients were followed up, all have an mRS score of zero or one.Conclusion:We conclude that for wide-necked aneurysms, stent-assisted coiling using the Solitaire AB is a safe and effective treatment option.

Regular Aspirin Use and Risk of Multiple Myeloma: A Prospective Analysis in the Health Professionals Follow-up Study and Nurses' Health Study

Multiple myeloma is a lethal malignancy with an unknown etiology and no prevention strategy. Aspirin inhibits several pathways mediated by NF-κB, COX-2, or their targets that are important in multiple myeloma pathogenesis. We conducted prospective analyses in the Health Professionals Follow-up Study and Nurses' Health Study cohorts to examine whether regular aspirin use influences multiple myeloma risk. We used biennially updated data to characterize aspirin use from baseline through a cancer diagnosis, death, or 2008. We applied a 4-year lag in exposure classification to diminish the influence of preclinical multiple myeloma on aspirin use habits. We obtained HRs and 95% confidence intervals (CI) from multivariable proportional hazard models to assess the association of aspirin use with multiple myeloma risk. We tested for trend across increasing quantity and duration of use. During 2,395,458 person-years, we confirmed 328 incident multiple myeloma diagnoses, including 265 with prospective information on typical aspirin dose and frequency. Participants with a cumulative average of ≥5 adult strength (325 mg) tablets per week had a 39% lower multiple myeloma risk than nonusers (HR; 95% CI, 0.61, 0.39-0.94; tablets per week, Ptrend = 0.06). Persons with ≥11 years of continuous regular aspirin use also had a lower multiple myeloma risk (HR; 95% CI, 0.63, 0.41-0.95; duration, Ptrend = 0.17). The associations appeared stronger in men than in women, possibly reflecting gender differences in aspirin use patterns. This prospective study of aspirin use and multiple myeloma supports an etiologic role for aspirin-inhibited (i.e., NF-κB- or COX-2 mediated) pathways. The utility of aspirin for multiple myeloma chemoprevention warrants further evaluation.