Coronary Stenting Procedures Research Articles

Influence of Race/Ethnicity and Sex on Coronary Stent Outcomes in Diabetic Patients.

How diabetes mellitus (DM), race/ethnicity, and sex impact ischemic events following coronary artery stent procedures is unknown. Using the PLATINUM Diversity and PROMUS Element Plus Post-Approval Pooled Study (N = 4184), we examined the impact of race/ethnicity, sex, and DM on coronary stent outcomes. Primary outcome was 1-year major adverse cardiac events (MACE) (MACE composite: death, myocardial infarction [MI], and target vessel revascularization). The study sample included 1437 diabetic patients (501 White men, 470 White women, 246 minority men, 220 minority women) and 2641 patients without medically treated DM (561 minority, 1090 women). Mean age (years) ranged from 61 in minority men to 65 in White women. Diabetic patients had a higher prevalence of atherosclerotic risk factors and comorbidities. Diabetic minority women (DMW; 70% Black, 27% Hispanic) had similar atherosclerotic risk factors to other diabetics, but experienced higher 1-year MACE (14.4% vs 7.5%, P <.01) and MI (4.3% vs 1.6%, P <.01) rates compared with patients without medically treated DM. No other diabetic cohort (White men, White women, minority men) showed an increased risk of MACE vs patients without medically treated DM. The incremental risk of MACE in DMW was associated with insulin use and persisted after risk adjustment (adjusted odds ratio 1.6 vs patients without medically treated DM; 95% CI, 1.0-2.5). Independent predictors of 1-year MACE included insulin use, hyperlipidemia, renal disease, and prior MI. DMW face the highest risk of ischemic events following coronary stenting, driven, in part, by insulin use. Aggressive secondary prevention and strict glycemic control are imperative in this cohort, and further research is warranted to elucidate the biologic mechanisms underpinning these observations. NCT02240810 (http://clinicaltrials.gov/).

In vitro biological responses of plasma nanocoatings for coronary stent applications.

In-stent restenosis and thrombosis remain to be long-term challenges in coronary stenting procedures. The objective of this study was to evaluate the in vitro biological responses of trimethylsilane (TMS) plasma nanocoatings modified with NH3 /O2 (2:1 molar ratio) plasma post-treatment (TMS + NH3 /O2 nanocoatings) on cobalt chromium (CoCr) alloy L605 coupons, L605 stents, and 316L stainless steel (SS) stents. Surface properties of the plasma nanocoatings with up to 2-year aging time were characterized by wettability assessment and x-ray photoelectron spectroscopy (XPS). It was found that TMS + NH3 /O2 nanocoatings had a surface composition of 41.21 ± 1.06 at% oxygen, 31.90 ± 1.08 at% silicon, and 24.12 ± 1.7 at% carbon, and very small but essential amount of 2.77 ± 0.18 at% nitrogen. Surface chemical stability of the plasma coatings was noted with persistent O/Si atomic ratio of 1.292-1.413 and N/Si atomic ratio of ~0.087 through 2 years. The in vitro biological responses of plasma nanocoatings were studied by evaluating the cell proliferation and migration of porcine coronary artery endothelial cells (PCAECs) and smooth muscle cells (PCASMCs). 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium (MTT) assay results revealed that, after 7-day incubation, TMS + NH3 /O2 nanocoatings maintained a similar level of PCAEC proliferation while showing a decrease in the viability of PCASMCs by 73 ± 19% as compared with uncoated L605 surfaces. Cell co-culture of PCAECs and PCASMCs results showed that, the cell ratio of PCAEC/PCASMC on TMS + NH3 /O2 nanocoating surfaces was 1.5-fold higher than that on uncoated L605 surfaces, indicating enhanced selectivity for promoting PCAEC growth. Migration test showed comparable PCAEC migration distance for uncoated L605 and TMS + NH3 /O2 nanocoatings. In contrast, PCASMC migration distance was reduced nearly 8.5-fold on TMS + NH3 /O2 nanocoating surfaces as compared to the uncoated L605 surfaces. Platelet adhesion test using porcine whole blood showed lower adhered platelets distribution (by 70 ± 16%), reduced clotting attachment (by 54 ± 12%), and less platelet activation on TMS + NH3 /O2 nanocoating surfaces as compared with the uncoated L605 controls. It was further found that, under shear stress conditions of simulated blood flow, TMS + NH3 /O2 nanocoating significantly inhibited platelet adhesion compared to the uncoated 316L SS stents and TMS nanocoated 316L SS stents. These results indicate that TMS + NH3 /O2 nanocoatings are very promising in preventing both restenosis and thrombosis for coronary stent applications.

The US Centers for Medicare &amp; Medicaid Services’ (CMS) failure to provide payment for invasive FFR has resulted in worse and inequitable Medicare beneficiary healthcare.

The unintended consequences of the US Centers for Medicare &amp; Medicaid Services’ (CMS) decision not to pay for invasive diagnostic FFR (Fractional Flow Reserve) has precluded its routine diagnostic use in hundreds of thousands of Medicare Beneficiaries, who suffered inappropriate coronary stent procedures (PCI) that worsened Medicare beneficiaries’ clinical outcomes: 20% of PCI patients have no or uncertain clinical indications but are operated upon, nevertheless, and 33% of potential PCI stenoses are non-ischemic and require no PCI. These unnecessary PCIs, often confounded by aging’s anatomical and comorbid complexities, result in preventable complications, repeat procedures, worse clinical outcomes, unwarranted deaths, and an avoidable $1 billion annual expenditure. The best coronary artery disease (CAD) patient care requires astute clinical assessment coupled with diagnostic physiologic ischemic lesion categorization, which directly links lesion treatment to patient management. CMS’ unrealistic expectation that their bundled payment to a single healthcare provider payment would motivate providers to maximize their profits through efficiently coordinated and improved care was naive; this foolish policy of eschewing invasive FFR payment and expecting providers to absorb the FFR pressure wire’s cost, has inflicted potential irreparable harm on all Medicare beneficiaries. CMS has forsaken its mission to attain the “highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, geography, preferred language, or other factors that affect access to care and health outcomes”.

Low incidence of hemorrhagic complications both during and after surgical procedures in patients maintained on prasugrel single antiplatelet therapy

Background and purposePrasugrel (Pra) is a third-generation thienopyridine that inhibits platelet aggregation via irreversible blockade of P2Y12 receptors. While several published studies have examined the use of Pra and acetylsalicylic acid (ASA) in coronary and neurovascular stenting procedures, there is only anecdotal evidence regarding the use of Pra as single antiplatelet therapy (SAPT) in open surgical procedures. This topic has become important because previous studies have revealed that neurovascular devices with antithrombotic coatings can be implanted using non-invasive procedures in patients maintained on Pra SAPT. Material and methodsPatients who underwent open surgery under Pra SAPT between March 2020 and February 2022 were evaluated retrospectively. Adequate platelet inhibition both before and after the procedures was verified in all patients using Multiplate (Roche Diagnostics) and VerifyNow (Accriva) tests. Intraoperative and postoperative hemorrhagic events were recorded based on reviews of the procedure reports and interviews with the surgeons. ResultsThe study enrolled 21 patients who underwent 23 open surgical procedures while maintained on Pra SAPT. The procedures included one extirpation of a brain arteriovenous malformation, seven extra-intracranial bypass surgeries, four ventriculoperitoneal shunts, one eye enucleation for an intractable orbital infection, two gastrostomies, one bone flap reinsertion after craniectomy, one decompressive craniectomy, one case requiring cranial surgical wound care, one colporrhaphy, one transurethral resection of urinary bladder cancer, two tumor oophorectomy/hysterectomy procedures, and one aneurysm clipping. None of the 23 procedures resulted in excessive intraoperative or postoperative hemorrhage. ConclusionIn a small retrospective series of patients who required antiplatelet therapy for neurovascular indications, Pra SAPT resulted in no significant increase in the incidence of perioperative and postoperative hemorrhagic complications.

Eisenmenger syndrome with left main compression syndrome: a case report

BackgroundLeft main coronary artery disease secondary to pulmonary artery compression related to Eisenmenger syndrome is an under-suspected condition that can cause fatal outcomes if left untreated. It presents with typical angina but is frequently mistaken for pulmonary hypertension (PH) symptoms. It is now recognized as one of the few important causes of angina in PH.Case presentationA 37-year-old man with a history of unoperated atrial septal defect and Eisenmenger syndrome came to the outpatient department with a chief complaint of angina on exertion. Electrocardiogram showed regular sinus rhythm with right axis deviation, right ventricular hypertrophy, deep T-wave inversion in inferior and anterior leads suggestive of ischemia or strain, and incomplete right bundle branch block. Cardiac CT showed compression of the left main coronary artery due to a dilated main pulmonary artery. Therefore, this patient was diagnosed with Eisenmenger syndrome with left main compression due to dilated pulmonary artery. He was treated successfully with IVUS-guided stent implantation. The patient experienced marked improvement in regular activities, with no recurrence of angina symptoms. Angiography 3 months after the procedure revealed good patency of the stent, without significant stenosis.ConclusionsLeft main coronary artery compression is a complication that should be suspected in patients with Eisenmenger syndrome presenting with angina symptoms. Non-invasive modalities are recommended for diagnostic evaluation, but the gold-standard technique remains coronary angiography. The best treatment is not well-established, with either myocardial revascularization or PH treatment, but a left main coronary artery stenting procedure is considered an ideal emergent treatment to provide a better quality of life for patients in this condition.

Abstract 9972: Estimation of DAPT Study Treatment Effects in Contemporary Clinical Practice: Findings from the EXTEND-DAPT Study

Introduction: Differences in patient characteristics, changes in treatment algorithms, and advances in medical technology could each influence the applicability of older randomized trial results to contemporary clinical practice. Objectives: To evaluate whether the Dual Antiplatelet Therapy (DAPT) Study population is different from a contemporary population of US patients receiving percutaneous coronary intervention (PCI), and to estimate the treatment effect of extended duration antiplatelet therapy after PCI in this more contemporary cohort. Methods: We compared characteristics of drug-eluting stent (DES)-treated patients randomized in the DAPT Study to a sample of more contemporary DES-treated patients in the NCDR CathPCI Registry from July 2016-June 2017. After linking trial and registry data, we employed inverse-odds of trial participation weighting to account for patient and procedural characteristics and estimated a contemporary “real-world” treatment effect of 30 vs. 12 months of DAPT after coronary stent procedures. Results: The US DES-treated trial cohort included 8864 DAPT Study patients and the registry cohort included 568,540 patients. Compared to the trial population, registry patients had more comorbidities and were more likely to present with myocardial infarction and receive 2nd generation DES. After reweighting trial results to represent the registry population, there was no longer a significant effect of prolonged DAPT on reducing stent thrombosis (reweighted treatment effect: -0.40, 95% CI: -0.99%, 0.15%), MACCE ( reweighted treatment effect: -0.52, 95% CI: -2.62%, 1.03%), or MI (reweighted treatment effect: -0.97%, 95% CI: -2.75%, 0.18%), but the increase in bleeding with prolonged DAPT persisted (reweighted treatment effect: 2.42%, 95% CI: 0.79%, 3.91%). Conclusions: Differences between patients and devices used in contemporary clinical practice compared with the DAPT Study may be associated with attenuation of benefits and relatively greater harms attributable to prolonged DAPT duration. These findings may limit applicability of average treatment effects from the DAPT Study in modern clinical practice.

Estimation of DAPT Study Treatment Effects in Contemporary Clinical Practice: Findings From the EXTEND-DAPT Study.

Differences in patient characteristics, changes in treatment algorithms, and advances in medical technology could each influence the applicability of older randomized trial results to contemporary clinical practice. The DAPT Study (Dual Antiplatelet Therapy) found that longer-duration DAPT decreased ischemic events at the expense of greater bleeding, but subsequent evolution in stent technology and clinical practice may attenuate the benefit of prolonged DAPT in a contemporary population. We evaluated whether the DAPT Study population is different from a contemporary population of US patients receiving percutaneous coronary intervention and estimated the treatment effect of extended-duration antiplatelet therapy after percutaneous coronary intervention in this more contemporary cohort. We compared the characteristics of drug-eluting stent-treated patients randomly assigned in the DAPT Study to a sample of more contemporary drug-eluting stent-treated patients in the National Cardiovascular Data Registry CathPCI Registry from July 2016 to June 2017. After linking trial and registry data, we used inverse-odds of trial participation weighting to account for patient and procedural characteristics and estimated a contemporary real-world treatment effect of 30 versus 12 months of DAPT after coronary stent procedures. The US drug-eluting stent-treated trial cohort included 8864 DAPT Study patients, and the registry cohort included 568 540 patients. Compared with the trial population, registry patients had more comorbidities and were more likely to present with myocardial infarction and receive 2nd-generation drug-eluting stents. After reweighting trial results to represent the registry population, there was no longer a significant effect of prolonged DAPT on reducing stent thrombosis (reweighted treatment effect: -0.40 [95% CI, -0.99% to 0.15%]), major adverse cardiac and cerebrovascular events (reweighted treatment effect, -0.52 [95% CI, -2.62% to 1.03%]), or myocardial infarction (reweighted treatment effect, -0.97% [95% CI, -2.75% to 0.18%]), but the increase in bleeding with prolonged DAPT persisted (reweighted treatment effect, 2.42% [95% CI, 0.79% to 3.91%]). The differences between the patients and devices used in contemporary clinical practice compared with the DAPT Study were associated with the attenuation of benefits and greater harms attributable to prolonged DAPT duration. These findings limit the applicability of the average treatment effects from the DAPT Study in modern clinical practice.

Validation of the computational model of a coronary stent: a fundamental step towards in silico trials

The proof of the reliability of a numerical model is becoming of paramount importance in the era of in silico clinical trials. When dealing with a coronary stenting procedure, the virtual scenario should be able to replicate the real device, passing through the different stages of the procedure, which has to maintain the atherosclerotic vessel opened.Nevertheless, most of the published studies adopted commercially resembling geometries and generic material parameters, without a specific validation of the employed numerical models.In this work, a workflow for the generation and validation of the computational model of a coronary stent was proposed. Possible sources of variability in the results, such as the inter-batches variability in the material properties and the choice of proper simulation strategies, were accounted for and discussed. Then, a group of in vitro tests, representative of the device intended use was used as a comparator to validate the model.The free expansion simulation, which is the most used simulation in the literature, was shown to be only partially useful for stent model validation purposes. On the other hand, the choice of proper additional experiments, as the suggested uniaxial tensile tests on the stent and deployment tests into a deformable tube, could provide further suitable information to prove the efficacy of the numerical approach.

Biointerface topography regulates phenotypic switching and cell apoptosis in vascular smooth muscle cells

BackgroundIn-stent restenosis (ISR) is a complex disease that occurs after coronary stenting procedures. The development of quality materials and improvement of our understanding on significant factors regulating ISR are essential for enhancing prognosis. Vascular smooth muscle cells (VSMCs) are the main constituent cells of blood vessel walls, and dysfunction of VMSCs can exacerbate ISR. Accordingly, in this study, we explored the influence of wrinkled material topography on the biological functions of VSMCs. MethodsPolydimethylsiloxane with a wrinkled topography was synthesized using elastomer base and crosslinking and observed by atomic force microscopy. VSMC proliferation, apoptosis, and morphology were determined by Cell Counting Kit-8 assays, fluorescence-assisted cell sorting, and phalloidin staining. α-Smooth muscle actin (α-SMA), major histocompatibility complex (MHC), and calponin 1 (CNN-1) expression levels were measured by quantitative real-time polymerase chain reaction and western blotting. Moreover, p53 and cleaved caspase-3 expression levels were evaluated by western blotting in VSMCs to assess apoptotic induction. ResultsSurface topographies were not associated with a clear orientation or elongation of VSMCs. The number of cells was increased on wrinkled surfaces (0.7 μm in amplitude, and 3 μm in wavelength [W3]) compared with that on other surfaces, contributing to continuously increased cell proliferation. Moreover, interactions of VSMCs with the W3 surface suppressed phenotypic switching, resulting in ISR via regulation of α-SMA, calponin-1, and SM-MHC expression. The surface with an amplitude of 0.05 μm and a wavelength of 0.5 μm (W0.5) promoted apoptosis by inducing caspase 3 and p53 activities. ConclusionIntroduction of aligned topographies on biomaterial scaffolds could provide physical cues to modulate VSMC responses for engineering vascular constructs. Materials with wrinkled topographies could have applications in the development of stents to reduce ISR.

Homozygous familial hypercholesterolemia in a young woman with dual gene mutations of low-density lipoprotein receptor and proprotein convertase subtilisin/kexin type 9

A 28-year-old woman with a rare combination of homozygous LDLR and heterozygous PCSK9 mutations had a phenotype consistent with homozygous familial hypercholesterolemia. She reported a clinical history of coronary and extracoronary atherosclerosis treated with 3 coronary stenting procedures, one coronary bypass, and aortic and mitral valve replacements. Because the patient refused lipoprotein apheresis, lipid-lowering therapy with statins, ezetimibe, and evolocumab was started. The desired low-density lipoprotein cholesterol target was not achieved. Dose-escalated lomitapide therapy (up to 30 mg/d) was added, enabling achievement of low-density lipoprotein cholesterol levels of 45 mg/dL during 24 months' follow-up. During this period, no cardiovascular events or clinical evidence of side effects occurred. In this case, lomitapide has been used in combination with maximum-tolerated statin therapy to successfully treat a patient with a rare combination of mutations in both LDLR and PCSK9 genes.

Role of and Recent Evidence for Antiplatelet Therapy in Prevention of Cardiovascular Disease in Diabetes

When treating patients with diabetes mellitus (DM), the benefits of antiplatelet therapy in preventing cardiovascular disease must be weighed against an increased risk of bleeding. Recent trials have sought to determine both the optimal anti-platelet regimen for patients with DM, and who specifically requires medication among the DM population. This paper will review recent trials and evidence recommending the use of antiplatelet therapy in the prevention of cardiovascular disease in patients with diabetes. Seven notable trials assessed the effectiveness of antiplatelet therapy in the DM population. The ASCEND trial concluded 100mg aspirin/day reduced rates of serious vascular events (OR 0.88, p < 0.01) but also increased rates of major bleeding events (OR 1.29, p < 0.01). The DAPT study revealed a longer dual antiplatelet regimen (30months vs. 18months) after coronary stent placement was more effective in reducing rates of stent thrombosis (0.5% vs. 1.1%, p = 0.06) and rates of myocardial infarction (3.5% vs. 4.8%, p = 0.06). DECLARE DIABETES showed that adding cilostazol to dual antiplatelet therapy after a coronary stent procedure reduced rates of in-stent and in-segment late loss and increased rates of revascularization (p < 0.04). In PEGASUS-TIMI, daily ticagrelor demonstrated reduced rates of major adverse cardiovascular and cerebrovascular events (OR 0.84, p < 0.04). The DAVID trial compared daily picotamide with daily aspirin therapy, finding reduced mortality rates in the picotamide group (OR 0.55, p < 0.05). Lastly, ACUITY found bivalirudin monotherapy resulted in lower rates of major bleeding events when compared to a glycoprotein IIb/IIa inhibitor and heparin or bivalirudin combination regimen (p < 0.01). Dual antiplatelet therapy guidelines still typically revolve around aspirin, but an increasing number of studies have demonstrated other drugs that may have a role in preventing atherosclerotic cardiovascular disease while decreasing the risk of major bleeding. Overall, it is wise to weigh the cardiovascular risk of a DM patient before prescribing antiplatelet medication. More research is necessary to determine a universal drug or combination of drugs that is safe and effective for DM patients.

Benefit and Risk of Prolonged DAPT After Coronary Stenting in Women.

Women may derive differential benefit from prolonged DAPT (dual antiplatelet therapy) after coronary stenting than men. We assessed whether the risks/benefits of prolonged DAPT differ between women and men. The DAPT study was a randomized double-blind, placebo-controlled trial comparing continued thienopyridine versus placebo beyond 12 months after coronary stenting. We compared rates of myocardial infarction, stent thrombosis, major adverse cardiovascular and cerebrovascular events, and bleeding by sex and randomized treatment. Of 11 648 patients, women (N=2925) were older, with higher prevalence of diabetes mellitus and lower rates of acute coronary syndrome than men. At 12 to 30 months, women had similar adjusted ischemic and bleeding events as men. The effects of continued thienopyridine therapy did not differ significantly by sex for stent thrombosis (women: hazard ratio [HR], 0.54; 95% confidence interval [CI], 0.22-1.36; men: HR, 0.26; 95% CI, 0.15-0.44; interaction P=0.17), myocardial infarction (women: HR, 0.75; 95% CI, 0.50-1.14; men: HR, 0.46; 95% CI, 0.36-0.60; interaction P=0.052), major adverse cardiovascular and cerebrovascular events (women: HR, 0.87; 95% CI, 0.62-1.22; men: HR, 0.70; 95% CI, 0.58-0.85; interaction P=0.26), and bleeding (women: HR, 1.45; 95% CI, 0.88-2.40; men: HR, 1.78; 95% CI, 1.28-2.49; interaction P=0.50). Women had similar late risks of ischemia and bleeding as men after coronary stent procedures. URL: https://www.clinicaltrials.gov . Unique identifier: NCT00977938.

Haemodynamic effects of incomplete stent apposition in curved coronary arteries.

Incomplete stent apposition (ISA, also known as malapposition) is a complication that affects day-to-day coronary stenting procedures. ISA is more prominent in complex arterial geometries, such as curvature, asa result of the limited conformability of coronary stents. These malapposed struts disturb the otherwise near-wall laminar blood flow and form a micro-recirculation environment. The micro-recirculation environment is often associated with low wall shear stress (WSS) and upsets the delicate balance of vascular biology, providing possible nidus for thrombosis and restenosis. In this study, a three-dimensional (3D) stent model was virtually deployed into an idealised curved coronary artery. Computational fluid dynamics (CFD) simulations were carried out to systematically analyse the haemodynamic effects of increasing maximum ISA distances, ranging from 180 (moderate), 400 (intermediate) to 910μm (severe) in an artery with decreasing radius of curvature (ROC). Micro-recirculations around both proximal and distal malapposed struts become more pronounced as compared to fully-apposed struts. The accompanying areas of low temporally-averaged WSS (AL-TAWSS) can increase twofold compared to the fully-apposed condition. Furthermore, substantial regions (∼5.2% and 9.0%) of AL-TAWSS are detached from the distal end of the malapposed struts in both moderate and intermediate cases respectively. Malapposed stents also induce more variation of TAWSS at the inner bend of the artery. At the stent surface, maximum WSS increases threefold from the fully-apposed case to intermediate ISA. High WSS on the strut surface is known to activate platelets which when exposed to the micro-recirculation environment may lead to their deposition and thrombosis.

Time in therapeutic range and major adverse outcomes in atrial fibrillation patients undergoing percutaneous coronary intervention: The Atrial Fibrillation Undergoing Coronary Artery Stenting (AFCAS) registry

Combination of oral anticoagulation (OAC) and antiplatelets is used in atrial fibrillation (AF) patients undergoing percutaneous coronary intervention and stent (PCI-S) procedure but is associated with increased bleeding when triple antithrombotic therapy (TAT) is used. Our aim was to analyze the impact of time in therapeutic range (TTR) on outcomes, in patients prescribed with TAT. Ancillary analysis from the AFCAS registry in patients assigned to TAT. TTR was calculated with Rosendaal method. Outcomes were analyzed according to TTR tertiles (T1 [≤56.8%] vs. T2 [56.9-93.8%] vs. T3 [≥93.9%]). Major bleeding was the primary outcome. Of 963 patients enrolled, 470(48.8%) were prescribed with TAT at discharge and qualified for this analysis. Median [IQR] TTR was 80.0% [45.3-100%]. After 359 [341-370] days, major bleeding rates were progressively lower with increasing TTR tertiles (T1 vs. T2 vs. T3: 10.3% vs. 4.7% vs. 2.3%, P=.006). Kaplan-Meier analysis demonstrated a progressively lower risk for major bleeding across tertiles (P=.006). Patients in the highest TTR tertile had a non-significant lower risk for major adverse coronary and cerebrovascular events (MACCE) (log-rank: 4.905, P=.086). Cox regression analysis showed that T2 and T3 were inversely associated with major bleeding (hazard ratio [HR]:0.39, P=.050 and HR: 0.21, P=.005). Continuous TTR was inversely associated with major bleeding (HR: 0.98, P<.001). For MACCE, adjusted Cox analysis found a non-significant lower risk for T3 (HR: 0.64, P=.128). In AF patients undergoing PCI-S prescribed TAT, good quality anticoagulation control (as reflected by TTR) was closely related to bleeding outcomes during follow-up. Despite some suggestive trends for an inverse relationship between TTR and MACCE, no definitive conclusions can be drawn, and further large studies are needed.

ANTIKOAGULIANTŲ IR ANTIAGREGANTŲ VARTOJIMAS AKIŲ CHIRURGIJOJE

Antikoaguliantų ir antiagregantų vartojimo supratimas atliekant akių chirurgines procedūras yra būtinas, siekiant išvengti sunkių hemoraginių komplikacijų operacijų metu ir pooperaciniu laikotarpiu. Dauguma pacientų, kuriems atliekamos kataraktos, antiglaukominės ar kitos oftalmologinės operacijos, yra vyresnio amžiaus ir reguliariai vartoja įvairių medicinos sričių specialistų paskirtus kraują skystinančius medikamentus. Įprasta prieš tam tikras akių intervencijas nutraukti antitrombozinį gydymą, taip sumažinant kraujavimo riziką, galinčią lemti net negrįžtamą regos praradimą. Krešumą mažinančių vaistų vartojimo nutraukimas gali sukelti tromboembolines komplikacijas, ypač pacientams, kuriems atliktos širdies vainikinių kraujagyslių stentavimo, šuntavimo operacijos ar protezuoti širdies vožtuvai. Įvykus sisteminėms komplikacijoms baigtys gali būti blogesnės nei lokalių akių komplikacijų atveju, įskaitant ir blogas gyvenimo prognozes. Atliekamų procedūrų metu stengiamasi išvengti bet kokių komplikacijų, tačiau į gydytojo oftalmologo kompetencijas neįeina kraują skystinančių vaistų skyrimas ar nutraukimas. Profesionaliam specialistų bendradarbiavimui svarbu suprasti kraują skystinančių medikamentų vartojimo reikšmę pacientams, kuriems atliekama tam tikra akių operacija.

In-stent restenosis after interventional treatment of carotid artery stenoses: a long-term follow-up of a single center cohort.

Whereas in-stent restenosis (ISR) is widely discussed after coronary stenting procedures, this phenomenon is a considerable problem after interventional treatment of carotid artery stenosis as well. We sought to quantify ISR rate and to identify important respective risk factors in our cohort. We retrospectively analyzed data of our carotid artery stenting database comprising 1165 angiographically successful interventional procedures during the last 19 years. Significant ISR was assessed by Doppler ultrasound and defined as a flow velocity exceeding 300cm/s representing a lumen narrowing >70%. Examinations were performed the day after intervention, at follow-up visits 1, 6 and 12 months after index hospitalization and once a year afterwards. Thirty-nine patients (3.4%) developed a significant ISR > 70% during the follow-up period (median 19.6 months, IQR 5.1-49.6 months). In 13 of them, restenosis was caused by a mechanical collapse (stent crush) of the implanted stent. All patients with significant ISR were free of neurological events during follow-up and 31 patients underwent a stent-in-stent implantation. We found a shorter stent length, a narrower stent diameter, performance of post-dilatation as well as stent type to significantly influence development of ISR. ISR > 70% after carotid artery stenting is a rare finding also during long-term follow-up. Especially in patients treated with balloon-expandable stents, post-dilatation reduced ISR significantly. As ISR was rare and clinically benign, this technique seems to remain a good therapy option in patients with significant carotid artery stenosis.

SC08.01 Impact and Management of Co-Morbidities

SC08.01 Impact and Management of Co-Morbidities

P3.04-023 Perioperative Management of Antiplatelet Therapy in Patients with Coronary Stent Who Need Thoracic Surgery: Topic: Miscellaneous I

Guidelines recommend delaying noncardiac surgery in patients after coronary stent procedures for 6 -12 months after drug-eluting stents (DES) and for 6 weeks after bare metal stents (BMS). It is often replaced by bridging heparin for the prevention of perioperative stent thrombosis in Japan, although there is no evidence for heparin replacement. The aim of this study was to investigate the perioperative complication between the patients with continuation of antiplatelet therapy (APT) and that with substitution of heparin after interruption of APT in thoracic surgery. A retrospective study was done on 75 patients after coronary stent procedures performed thoracic surgery with APT or bridging heparin in perioperative from June 2008 to October 2015. We evaluated the perioperative outcomes between the patients with APT (APT group) and that with bridging heparin interrupting APT (non APT group). Males were 13 cases (76%) and median age was 73.5 years in APT group. Fifteen cases (88%) with APT had angina in past history. The type of stent was drug eluting stent (71%), bare metal stent (24%) and biological absorption stent (6%) in APT group. Surgical procedures with wide wedge resection (12%), segmentectomy (12%), lobectomy (71%), and others (6%) were performed in APT group. Median operative time was 119 minutes and median operative blood loss was 18ml in APT group. There was no difference with operative time and blood loss in APT group compared in non APT group (p=0.128 and p=0.923). Cardiovascular events was not observed in both groups. One case had Hemothorax and reoperation in APT group and one case had hemosputum in non APT group. There was no difference in complication in both groups. Perioperative death was not observed in both groups. There was no difference between the patients with and without the discontinuation of antiplatelet agent in perioperative cardiovascular and embolic events. On the other hand, it seems that the compensatory of bleeding to continue antiplatelet agent is too large, because a few cases were forced completion pneumonectomy and acute exacerbation of interstitial pneumonia due to bleeding. Among the patients with coronary stent undergoing thoracic surgery, it might be less the benefits of the surgery with continuation of antiplatelet agent.

Competitive Coronary Flow between the Native Left Anterior Descending Artery and Left Internal Mammary Artery Graft: Is It a Surrogate Angiographic Marker of Over-or-Unnecessary Revascularization Decision in Daily Practice?

Overdiagnosis and overtreatment are often thought of as relatively recent phenomena in modern medicine, influenced by a contemporary combination of technology, specialization, payment models, marketing, and supply-related demand. Several investigators have reported discrepancies between the angiographic and functional severity of coronary angiographic stenosis. However, the visual anatomic assessment of the coronary lesion severity continues in daily practice. We evaluated the consecutive all coronary angiograms performed between January 2015 and December 2015 and examined only patients who had previous coronary artery bypass grafting (CABG) to analyze the cases with regard to presence of the competitive flow (CF) between the native left anterior descending coronary artery (LAD) and left internal mammary artery (LIMA) graft. A total of 8,248 diagnostic coronary angiographies were performed between January 2015 and December 2015 at our facility. Of these, 886 coronary angiographies of CABG patients were detected. Whereas LIMA graft occlusion detected in 19 patient (2.1%), the LIMA-LAD CF rate was found in 86 (9.7%) CABG patients. The angiographic severity of the LAD stenosis in CF group evaluated as mild in 20 (25%), moderate in 61 (70%), and severe coronary artery disease in 4 (5%) patients. Our results showed that there is 9.7% rate of LIMA-LAD CF. Therefore, some unnecessary coronary stenting or CABG procedures might have been performed due to limited use of functional testing for clinical decision making. The functional angiography should play a more prominent role in catheterization laboratories as recommended by current revascularization guidelines to prevent overdiagnosis, misdiagnosis, or incorrect treatment decisions.

Do pre-procedural laboratory parameters predict drug-eluting stent restenosis?

Drug-eluting stents (DES) have considerably reduced the rates of in-stent restenosis (ISR). Several studies reported pre-procedural C-reactive protein (CRP), neutrophil to lymphocyte (N/L) ratio, red cell distribution width (RDW), serum uric acid (UA), and mean platelet volume (MPV) as independent predictors of ISR using bare metal stents. This study investigates whether any laboratory parameter obtained before the coronary stenting procedure is associated with ISR using DES in stable coronary artery disease. Three hundred fifteen stents were retrospectively analysed in 285 patients who had undergone coronary stenting and a control coronary angiography within one year of stenting, between January 2012 and April 2014. Pre-procedural complete blood count, biochemistry, and CRP were recorded. Off-line quantitative coronary angiography analysis was performed. Overall restenosis rate was 10.2%. When the stents were analysed with respect to the presence of ISR, the number of diabetics and smokers was higher in the ISR group. CRP levels were significantly higher in the ISR group, but there were no differences in N/L, monocytes, eosinophils, RDW, MPV, UA, and total bilirubin levels. In the univariate regression analysis, DM, CRP, stent length, stent diameter, pre-procedural diameter stenosis, pre-procedural minimal lumen diameter (MLD), post-procedural residual diameter stenosis, post-procedural reference vessel diameter, and post-procedural MLD were predictors of ISR. However, multivariate regression analysis identified only DM and post-procedural residual stenosis as independent predictors of ISR. Pre-procedural blood parameters do not independently predict ISR in DES, which is mainly determined by the presence of diabetes and post-procedural residual stenosis.