Drug-eluting Stent Placement Research Articles

Safety And Efficacy Of Drug-eluting Stents For Treatment Of Transplant Renal Artery Stenosis

<h3>INTRODUCTION AND OBJECTIVES</h3> There is a paucity of clinical data on use of drug-eluting stent (DES) for transplant renal artery stenosis (TRAS). Therefore, we investigated outcomes of patients with clinically significant TRAS undergoing DES placement. <h3>METHODS</h3> A retrospective review of patients with clinically significant TRAS undergoing percutaneous balloon angioplasty with DES from 2014 to 2021 was conducted. Patient demographics, procedural details, and follow-up outcomes were collected. Primary endpoints were the in-stent primary patency and graft survival. Secondary endpoints were freedom from reintervention and primary-assisted patency <h3>RESULTS</h3> Thirteen TRAS in twelve patients with graft function alteration were treated with DES. The median age was 57 years (interquartile range (IQR), 48-63), and nine (75%) were male. The median follow-up was 9 months (IQR, 4-52). The median time from transplant to intervention was 5.8 months. TRAS was most commonly found at the proximal portion (92%). The procedure was performed with carbon dioxide angiography with minimal amount of contrast (median, 3 mL) under local and general anesthesia in nine (69%) and four (21%) TRAS, respectively. The rates of stenosis-free primary patency of the DES and graft survival were 75% and 100%, respectively. Three reinterventions for restenosis resulted from the kinking of the transplant renal artery proximal to the DES, which were treated by extending the stent more proximally into the origin of the transplant renal artery. The median time to reintervention was 0.9 months (range, 0.23-2 months). Freedom from reintervention and primary-assisted patency were 75% and 100%, respectively. <h3>CONCLUSIONS</h3> Despite the lack of evidence in literature, these data demonstrate that DES is safe and effective in treating patients with TRAS at short to midterm. As all reinterventions after DES were performed due to kinking of the transplant renal artery proximal to the stent, bridging of the DES into the external iliac artery is recommended.

Adherence to dual antiplatelet therapy after coronary stenting: A study conducted at two Vietnamese hospitals.

Introduction: Adherence to dual antiplatelet therapy (DAPT) is critical after drug-eluting stent(DES) placement. We aimed to assess patient’s knowledge, rates of DAPT adherence, trends in DAPT use over time, and patient‐level factors associated with nonadherence in the patient with acute coronary syndrome (ACS). Methods: ACS patients who received one or more DES between May and September 2018from two hospitals in Vietnam and used DAPT after stent placement were eligible for a direct interview to assess patient’s knowledge on disease and DAPT. Telephone interviews were conducted one, three, and six months following discharge. Nonadherence was defined as premature discontinuation of DAPT. Factors related to nonadherent patients were analyzed using the chi-square test. Results: Of the 200 patients identified, 154 (77%) participated. Of the ten questions related to knowledge, the mean score of correct answers was 8.2 ± 2.3, and 71.7% had good knowledge.Adherence to DAPT was high at one month (94.2%) but declined by three months (44.2%) and then by six months (46.8%). Aspirin adherence was 99.3%-100% throughout. Three factors associated with nonadherence of DAPT following DES placement by six months included: rural location, linactive occupation, and inadequate knowledge on disease and DAPT (p <0.05). Conclusion: DAPT adherence is high at one month but is suboptimal at three and six months.Factors associated with the nonadherence of DAPT will be helpful in the planning of patient education strategies.

Early- and Middle-Phase Angioscopic Assessment of Arterial Healing Following Current Drug-Eluting Stent Implantation in Patients With Acute Coronary Syndrome.

Background: Drug-eluting stents (DESs) have been widely used for the treatment of acute coronary syndrome (ACS). However, there are few reports on early- and middle-phase arterial repair after DES implantation in ACS patients.Methods and Results: Coronary angioscopy (CAS) findings covering the early and middle phases (mean [±SD] 4±1 and 10±2 months, respectively) of arterial healing after second- and later-generation DES placement between May 2009 and January 2020 were extracted from the Kansai Rosai Hospital Cardiovascular Center database. Neointimal coverage (NIC), yellow color intensity, and the incidence of thrombus adhesion were compared between ACS and chronic coronary syndrome (CCS) in the early (54 stents of 47 lesions, 38 ACS patients; 86 stents of 70 lesions, 52 CCS patients) and middle (179 stents of 154 lesions from 136 ACS patients; 459 stents of 374 lesions from 287 CCS patients) phases. In the early phase, NIC, the incidence of thrombus adhesion (ACS, 39.1%; CCS, 38.0%), and maximum yellow color grade were similar between the 2 groups. In the middle phase, although the maximum yellow color grade was significantly higher in the ACS group (P=0.013), NIC and the incidence of thrombus adhesion (ACS, 24.6%; CCS, 23.4%) were similar in the 2 groups.Conclusions: Arterial healing assessment with CAS showed that NIC and the incidence of thrombus adhesion after DES implantation were similar between ACS and CCS patients.

Coil Embolization of Iatrogenic Femoral Artery Pseudoaneurysm

<h3>Introduction and Objective</h3> Femoral pseudoaneurysms are not uncommon after cardiac catheterizations. Multiple methods are used to treat pseudoaneurysms including ultrasound guided thrombin injection, direct pressure, stent grafting, open surgical repair and endovascular coil embolization. We describe a patient with severe comorbidities with complicated femoral pseudoaneurysm treated with emergent coil embolization via radial access. <h3>Case Report</h3> An obese 77-year-old female with multiple comorbidities, who was deemed a prohibitive risk for cardiac surgery, was taken to the cardiac cath lab for percutaneous coronary intervention. She underwent balloon valvuloplasty of the aortic valve in addition to placement of drug-eluting stents in the left main, LAD, diagonal and circumflex arteries. This was accomplished through a 10 French sheath placed in the left common femoral artery. The groin was closed with two Perclose devices. An immediate hematoma developed in the left groin. Manual pressure was held until the patient was stable. She was then transported to the ICU. Shortly after arrival in the ICU, the patient developed hypotension. She was taken back to the cardiac cath lab where she underwent an arteriogram via the left radial artery. Contrast extravasation was noted from the left femoral artery. Several attempts to control hemorrhage with balloon occlusion were unsuccessful. Urgent vascular surgery consultation was obtained. Patient was emergently moved to the endovascular operating room. Left femoral arteriography via left radial access revealed active contrast extravasation from the femoral bifurcation into a large pseudoaneurysm cavity. A vertebral catheter was used to advance a glide wire into the pseudoaneurysm. A microcatheter was then advanced into the pseudoaneurysm cavity. The pseudoaneurysm was embolized with two detachable 6 × 12 Penumbra Ruby coils. Post embolization, there was minimal flow into the pseudoaneurysm. Duplex ultrasound performed the next day revealed minimal flow in the pseudoaneurysm cavity with a maximal flow lumen of 1 cm. This was observed and it spontaneously thrombosed. The patient ultimately recovered and returned to her baseline medical status. <h3>Discussion</h3> A variety of methods are available for the treatment of pseudoaneurysms. Traditional treatment options include ultrasound-guided manual compression, thrombin injection and open surgery. With the development and evolution of endovascular techniques, less invasive options such as stent graft coverage and coil embolization can be successfully utilized. There are few case reports of coil embolization of femoral pseudoaneurysms. In selected patients, coil embolization may be an effective alternative to surgical treatment and can be offered by the vascular surgeon.

United States Investigational Device Exemption study of the Revolution Peripheral Atherectomy System

ObjectiveAtherectomy has become commonplace as an adjunct to interventional treatments for peripheral arterial disease, but the procedures have been complicated by risks including distal embolization and arterial perforation. This study aimed to examine the safety and effectiveness of a novel atherectomy system to treat femoropopliteal and below-knee peripheral arterial disease. MethodsThe Revolution Peripheral Atherectomy System (Rex Medical LP, Conshohocken, Pa) was studied in 121 patients with 148 femoropopliteal and below-knee lesions, enrolled at 17 United States institutions. Technical success was defined when the post-atherectomy angiographic stenosis was ≤50%, as assessed by an independent core laboratory. Major adverse events were adjudicated by an independent Clinical Events Committee. ResultsAmong 148 site-identified target lesions in 121 patients, 21.4% were in the superficial femoral artery, 13.7% involved the popliteal artery, and 67.9% were in tibial arteries; 3.1% involved more than one segment. Technical success was 90.2%, with stenoses decreasing from 73% ± 19% at baseline to 42% ± 14% after atherectomy. Adjunctive treatment after atherectomy included angioplasty with uncoated balloons in 91%, drug-coated balloons in 11%, bare stent deployment in 8%, and drug-eluting stent placement in 3%. Procedural success (<30% residual stenosis) was achieved in 93.7% of target lesions. Complications during the procedure included one target vessel perforation and two distal embolizations; each of which were adjudicated by the Clinical Events Committee as unrelated to the device and were not visualized angiographically by the core laboratory. Freedom from major adverse events was 97.3% through 30 days. The Kaplan-Meier estimates of primary, assisted primary, and secondary patency were 81.6%, 87.7%, and 91.6% at 6 months, respectively. ConclusionsThe use of the Revolution Peripheral Atherectomy System was associated with few procedural complications and a high rate of success at the index procedure and through 6 months.

BLAST INJURY AS A CAUSE OF AN AORTIC THROMBUS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: We report a 31-year-old male with a single gunshot wound (GSW) to the left back who developed an aortic thrombosis within twenty-four hours after presentation. Vascular pathology following a penetrating trauma, specifically to the chest, without direct aortic injury is profoundly rare and could cause devastating sequelae. CASE PRESENTATION: A 31-year-old male, with no past medical history, presents with a single GSW to the left back inferior to the scapula. Upon imaging the patient, he was found to have a large left pneumohemothorax, lung laceration, and a retained missile between the descending thoracic aorta and the eighth thoracic vertebral body in the posterior mediastinum. A chest tube (CT) was placed with immediate collection of 1500cc of sanguineous output. After this initial bloody drainage, CT output decreased significantly to less than 150 cc/hour, so no vascular or thoracic intervention was immediately planned. Notably, initial computerized tomography angiogram (CTA) chest and close follow up with a second CTA showed no aortic injury. Repeat CTA chest at 24 hours was performed for monitoring of potential vascular pathology which demonstrated a new nonocclusive thrombus in the descending thoracic aorta adjacent to the bullet fragment which measured 8 x 9 mm. The patient was asymptomatic, however, due to the increased risk of distal embolization, he was taken urgently to the operating room for thoracic endovascular aortic stent placement. The patient recovered well and was discharged. DISCUSSION: Ballistic injury has been studied extensively, especially during wartime. These projectiles cause shockwaves throughout the area of injury that extend beyond the projectile tract and can cause intimal injury of vessel which manifest as thrombus, dissection, or aneurysm formation. With no observed direct aortic injury, the vascular injury is presumed to be secondary to the blast injury from the GSW. We previously presented a case report where a 100% obstructing left anterior descending cardiac artery thrombus was found twenty-four hours after a GSW to the chest, in a young healthy male. This required emergent cardiac catheterization and drug eluting stent placement. This case series suggests that the blast injury from a bullet extends beyond the direct damage from the bullet and careful attention to surrounding vasculature must be observed. CONCLUSIONS: Our case highlights the importance of having high clinical suspicion of tissue injury adjacent to GSW tracts. In this case series, vascular structures were never directly injured, yet vascular pathology was found requiring operative intervention. Shockwaves caused by these projectiles can cause thrombus, dissection, and aneurysm formation when traveling in close proximity to vessels. REFERENCE #1: Reade Michael, Thomas Peter. (2016). Pathophysiology of ballistic trauma. 10.1093/med/9780199600830.003.0339 REFERENCE #2: Eletta, Olanrewaju et al. (2020) A case report of myocardial infarction from a gunshot wound to the chest https://www.sciencedirect.com/science/article/pii/S0012369220324211 REFERENCE #3: Shin EH, Sabino JM, Nanos GP 3rd, Valerio IL. Ballistic trauma: lessons learned from iraq and afghanistan. Semin Plast Surg. 2015;29(1):10-19. doi:10.1055/s-0035-1544173 DISCLOSURES: No relevant relationships by Kevin Dong, source=Web Response No relevant relationships by Lewis Schwartz, source=Web Response No relevant relationships by Amy Stewart, source=Web Response

Management of Stent Thrombosis Post-Percutaneous Coronary Intervention and Associated Rare Complications

Stent thrombosis is a devastating complication of percutaneous coronary intervention (PCI) associated with significant morbidity and mortality. Progressive technical advancements from balloon angioplasty to bare-metal stent and drug-eluting stent placement have reduced the incidence of stent thrombosis. Definitive management and preventive methods are still negligible. Here, we describe two cases of definite subacute stent thrombosis of the right coronary complicated by pericarditis and very late left anterior descending stent thrombosis after the intervention in the right coronary artery. In both cases, antiplatelet treatment with clopidogrel showed excellent compliance. Therefore, after successful PCI, we switched both cases from clopidogrel to potentially more potent antiplatelet treatment, such as ticagrelor, to reduce the occurrence of stent thrombosis in the future.

In-Hospital Outcomes of Patients With Non-Alcoholic Fatty Liver Disease Who Underwent Percutaneous Coronary Intervention: A Nationwide Inpatient Sample Analysis.

BackgroundNon-alcoholic fatty liver disease (NAFLD) is prevalent in almost 25% of the Western population and is predicted to become one of the leading causes of end-stage liver disease. There is increasing evidence that NAFLD is a risk factor for cardiovascular disease, specifically for coronary artery disease, via disruption of the metabolism of glucose and lipids in the body, leading to a state of systemic inflammation that promotes atherosclerosis. This study aims to explore outcomes in patients who underwent percutaneous coronary intervention (PCI) with or without placement of drug-eluting stents (DES) to determine whether the concurrent diagnosis of NAFLD led to worse in-hospital outcomes.MethodsWe used the National Inpatient Sample, Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality 2016 to conduct a cross-sectional study that included all adult patients who underwent PCI with or without placement of DES during hospital admission. Patients with NAFLD were identified and compared to patients without NAFLD. Patients were selected by using ICD-10-CM and ICD-10-PCS codes. Outcomes included mortality, length of stay and total hospital charges, and major adverse cardiac events (MACE). Data on patient demographics, inpatient statistics, and comorbidities were obtained and analyzed using cross-tabulation, Pearson χ2 test, and independent samples t-test. Data were adjusted for confounders using logistic and linear regression.ResultsAmong 429,855 patients who underwent PCI with or without placement of DES, 2,560 patients (0.6%) had a diagnosis of NAFLD. There was no significant difference with regard to mortality and MACE. The NAFLD group had a higher proportion of females, a longer average length of hospital stay, and patients presented at a younger average age. Regarding comorbidities, more patients in the NAFLD group had diabetes mellitus type II, obesity, obstructive sleep apnea (OSA), chronic kidney disease (CKD), and peripheral vascular disease (PVD).ConclusionNAFLD is emerging as a risk factor for cardiovascular disease. Increasing evidence suggests that the disease contributes to systemic atherosclerosis and thus coronary artery disease. We found that among patients who underwent PCI in 2016, those with NAFLD had a longer length of stay, were admitted at a younger age, and had significantly more cardiovascular comorbidities than those without NAFLD. Increasing evidence has shown that advanced liver disease due to NAFLD will continue to place a significant burden on the healthcare system and is, therefore, an area that the medical community should continue to focus on, especially, regarding preventative and therapeutic efforts.

Temporal Changes in Near-Infrared Spectroscopy Signals in Recurrent In-Stent Restenosis Attributable to Calcified Nodule

A 75-year-old man had recurrent in-stent restenosis (ISR) attributable to calcified nodule. Near-infrared spectroscopy (NIRS) showed a gradual decrease in yellow signals during the process of repeated percutaneous coronary intervention for recurrent ISR that eventually halted. The case indicates that NIRS signals may represent lesion instability even in calcified nodule, and may be potentially predictive of recurrent ISR.

Aneurysmal degeneration of fluoropolymer-coated paclitaxel-eluting stent in the superficial femoral artery: a rising concern

BackgroundAlthough several clinical reports demonstrated a durable patency rate after a novel fluoropolymer-coated paclitaxel-eluting stent (Eluvia; Boston Scientific, Marlborough, MA, USA) placement, aneurysmal degeneration after drug-eluting stent (Eluvia) placement has raised clinical concerns. Here, we report a case with progressive aneurysm formation on serial angiography and intravascular ultrasound over 50 months after drug-eluting stent (Eluvia) placement for a superficial femoral artery atheromatous plaque.Case presentationA 79-year-old woman with right leg intermittent claudication at 100 m distance was referred to our hospital. Pre-procedural angiography showed long-segment severe stenosis from the middle-to-distal part of the right superficial femoral artery, and a 7 mm wide drug-eluting stent (Eluvia) was placed. However, the patient had a recurrence of intermittent claudication in the right lower extremity 25 months thereafter. Angiography revealed de novo stenosis in the distal part of the popliteal artery and proximal superficial femoral artery in-stent restenosis. Subsequently, the patient underwent endovascular therapy for these lesions. In addition, intravascular ultrasound at the time of endovascular therapy revealed femoral artery enlargement with a maximum vessel diameter of 10.0 mm at the distal edge of the stent. Intermittent claudication on the right side recurred again 50 months after drug-eluting stent (Eluvia). Angiography demonstrated de novo severe stenosis from the distal part of the superficial femoral artery to the middle part of the popliteal artery. Peri-stent contrast staining was found at the distal part of the drug-eluting stent (Eluvia) site. Intravascular ultrasound showed a further enlargement of maximum vessel diameter to 12.0 mm at the distal edge of the stent.ConclusionsWe report a case with progressive aneurysm degeneration on serial angiography and intravascular ultrasound over 50 months after drug-eluting stent (Eluvia) placement for a superficial femoral artery stenosis.

Perioperative dual antiplatelet therapy for patients undergoing spine surgery soon after drug eluting stent placement.

Background: Performing emergent spinal surgery within 6 months of percutaneous placement of drug-eluting coronary stent (DES) is complex. The risks of spinal bleeding in a “closed space” must be compared with the risks of stent thrombosis or major cardiac event from dual antiplatelet therapy (DAPT) interruption.Methods: Eighty relevant English language papers published in PubMed were reviewed in detail.Results: Variables considered regarding surgery in patients on DAPT for DES included: (1) surgical indications, (2) percutaneous cardiac intervention (PCI) type (balloon angioplasty vs. stenting), (3) stent type (drug-eluting vs. balloon mechanical stent), and (4) PCI to noncardiac surgery interval. The highest complication rate was observed within 6 weeks of stent placement, this corresponds to the endothelialization phase. Few studies document how to manage patients with critical spinal disease warranting operative intervention within 6 months of their PCI for DES placement.Conclusion: The treatment of patients requiring urgent or emergent spinal surgery within 6 months of undergoing a PCI for DES placement is challenging. As early interruption of DAPT may have catastrophic consequences, we hereby proposed a novel protocol involving stopping clopidogrel 5 days before and aspirin 3 days before spinal surgery, and bridging the interval with a reversible P2Y12 inhibitor until surgery. Moreover, postoperatively, aspirin could be started on postoperative day 1 and clopidogrel on day 2. Nevertheless, this treatment strategy may not be appropriate for all patients, and multidisciplinary approval of perioperative antiplatelet therapy management protocols is essential.

Coronary Stent Healing in Cancer Patients-An Optical Coherence Tomography Perspective.

Objective: This study assessed stent healing patterns and cardiovascular outcomes by optical coherence tomography (OCT) in cancer patients after drug-eluting stent (DES) placement.Background: Cancer treatment, owing to its cytotoxic and antiproliferative effects, could delay stent healing and increase stent thrombosis risk, especially when dual antiplatelet therapy (DAPT) is discontinued early for oncological treatment. OCT can assess stent endothelialization and other healing parameters, which may provide clinical guidance in these challenging scenarios.Methods: This single-center retrospective study enrolled all cancer patients who underwent OCT for assessment of vascular healing patterns after prior DES placement from November 2009 to November 2018. Primary study endpoints were stent healing parameters, including stent coverage, apposition, degree of expansion, neointimal hyperplasia heterogeneity, in-stent restenosis, stent thrombosis, and overall survival (OS).Results: A total of 67 patients were included in this study. Mean time between DES placement and OCT evaluation was 154 ± 82 days. Stent healing matched published values for DES in non-cancer patients (P ≥ 0.063). At 1 year, the OS was 86% (95% confidence interval [CI]: 78–96%) with 0% incidence of acute coronary syndrome. Advanced cancers and active chemotherapies were associated with inferior OS (P = 0.024, hazard ratio [HR]: 3.50, 95% CI: 1.18–10.42 and P = 0.026, HR: 2.65, 95% CI: 1.13–6.22, respectively), while stent healing parameters were unassociated with OS. Forty-one patients (61%) had DAPT duration ≤6 months.Conclusions: Stent healing of contemporary DES appears similar in cancer and non-cancer patients. Cardiovascular risk of cancer patients after DES placement can be managed to facilitate timely cancer therapies, as the underlying malignancy and active chemotherapy ultimately determine survival.

Abstract No. 12 Stay alive: drug-eluting versus bare-metal stent mortality rates in a high-volume vascular center

Since the paclitaxel conundrum set forth in 2018 by Katsanos et al, the safety profile of DET has been under scrutiny with concerns of increased mortality, despite higher rates of freedom from target lesion revascularization. As a dedicated limb salvage center treating Rutherford classification (RC) 3-6 patients, we performed a retrospective analysis of our single-center data evaluating mortality outcomes in patients after bare-metal versus drug-eluting stent (DES) placement.

TCTAP A-031 Retrospective Comparison of Midterm Clinical Outcomes After Drug-coated Balloon Dilation Versus Drug-eluting Stents Placement for De-novo Stenosis in Large Vessel

TCTAP A-031 Retrospective Comparison of Midterm Clinical Outcomes After Drug-coated Balloon Dilation Versus Drug-eluting Stents Placement for De-novo Stenosis in Large Vessel

Comparison of Hospitalization Trends and Outcomes in Acute Myocardial Infarction Patients With Versus Without Opioid Use Disorder

Discrepancies in medical care are well known to adversely affect patients with opioid abuse disorders (OUD), including management and outcomes of acute myocardial infarction (AMI) in patients with OUD. We used the National Inpatient Sample was queried from January 2006 to September 2015 to identify all patients ≥18 years admitted with a primary diagnosis of AMI (weighted N = 13,030; unweighted N = 2,670) and concomitant OUD. Patients using other nonopiate illicit drugs were excluded. Propensity matching (1:1) yielded 2,253 well-matched pairs in which intergroup comparison of invasive revascularization strategies and cardiac outcomes were performed. The prevalence of OUD patients with AMI over the last decade has doubled, from 163 (2006) to 326 cases (2015) per 100,000 admissions for AMI. The OUD group underwent less cardiac catheterization (63.2% vs 72.2%; p <0.001), percutaneous coronary intervention (37.0% vs 48.5%; p <0.001) and drug-eluting stent placement (32.3% vs 19.5%; p <0.001) compared with non-OUD. No differences in in-hospital mortality/cardiogenic shock were noted. Among subgroup of ST-elevation myocardial infarction patients (26.2% of overall cohort), the OUD patients were less likely to receive percutaneous coronary intervention (67.9% vs 75.5%; p = 0.002), drug-eluting stent (31.4% vs 47.9%; p <0.001) with a significantly higher mortality (7.4% vs 4.3%), and cardiogenic shock (11.7% vs 7.9%). No differences in the frequency of coronary bypass grafting were noted in AMI or its subgroups. In conclusion, OUD patients presenting with AMI receive less invasive treatment compared with those without OUD. OUD patients presenting with ST-elevation myocardial infarction have worse in-hospital outcomes with increased mortality and cardiogenic shock.

Abstract 15440: Bleeding Complications May Outweigh the Risk of Thrombosis in Patients With End-stage Liver Disease Taking Dual Antiplatelet Therapy After Percutaneous Coronary Intervention

Introduction: Randomized trials have demonstrated the safety and efficacy of one month of dual antiplatelet therapy (DAPT) after placement of drug-eluting stents in patients with high bleeding risk. Patients with end-stage liver disease (ESLD) are underrepresented in these trials. Patients who undergo percutaneous coronary intervention (PCI) in preparation for orthotopic liver transplantation (OLT) exhibit a high incidence of bleeding complications on DAPT. The rates of bleeding versus thrombotic complications in ESLD patients placed on DAPT following PCI are poorly described. Methods: We retrospectively collected data from 61 patients who were evaluated for OLT between 2016 and 2019 and underwent PCI prior to listing. Bleeding events were classified using the Bleeding Academic Research Consortium (BARC) definitions and included if the following criteria were met: events occurred in the setting of DAPT, were non-procedural in etiology, and occurred during the time following PCI and prior to OLT. Ischemic complications were evaluated by the incidence of myocardial infarction (MI), stent thrombosis, in-stent restenosis (&gt;50%) and all-cause mortality at 1 year follow-up. Results: A total of 55/61 patients (90%) were placed on DAPT following PCI. Among them, 21/55 patients (38%) bled while taking DAPT, including 15 patients (27%) with BARC types 3-5 first-time bleeding events and 10 patients (18%) requiring early discontinuation of therapy. The median time to first bleeding event was 8 days (range 1 to 477 days, 85 th percentile 17 days). Among ischemic complications, MI occurred in 11/55 patients (20%) however only one patient had a type 1 MI with the remaining being type 2 in etiology. There were no episodes of stent thrombosis and 2 episodes of in-stent restenosis during the 1 year follow-up. A total of 12/55 patients (22%) went on to receive OLT and 18/55 (33%) passed away by 1 year post-PCI. Conclusions: Patients with ESLD exhibit a high rate of clinically significant bleeding on DAPT when compared to overall thrombotic events. The majority of bleeds occurred within the first month after PCI. These findings illustrate the need for larger studies to assess the safety of single instead of dual antiplatelet therapy in patients with ESLD who receive PCI.

Abstract 15121: Mortality in Cancer Patients Undergoing Percutaneous Coronary Intervention: Insights From a Hospital-based Cross-sectional Study

Introduction: Comorbid risk factors between cancer and coronary artery diseases (CAD) and underlying pathogenesis of inflammation and oxidative stress led to an increase in the number of cancer patients developing CAD. Hypothesis: The prime purpose of our hospital-based study is to evaluate the risk of mortality due to cancer and chronic comorbidities in post-percutaneous coronary intervention (PCI) patients. Methods: We conducted a cross-sectional study using the nationwide inpatient sample (NIS, 2012 to 2014) including 1,131,415 adult patients undergoing PCI with placement of non-drug and/or drug-eluting coronary artery stents. The logistic regression model was used to assess the odds ratio (OR) of the association between comorbid cancer and mortality in post-PCI hospitalized patients. Results: Most of the post-PCI patients with cancer were older adults (mean age 70.6 years), males (71.8%), and Caucasians (80.6%). Females (OR 1.28, 95% CI 1.24-1.34) had higher odds of post-PCI mortality risk compared to males. Among all comorbidities, coagulopathy and deficiency anemia were associated with increased risk of mortality by three times (95% CI 2.837-3.250) and 1.6 times (95% CI 1.534-1.692), respectively in post-PCI hospitalized patients. Comorbid cancer was associated with an increased risk of mortality in post-PCI hospitalized patients (OR 1.88, 95% CI 1.69-2.09) after controlling for potential confounders. Conclusions: Cancer is a significant risk factor increasing the risk of mortality by 88% in post-PCI hospitalized patients. An integrated care model requiring more vigilance and aggressive management for the complex patient population with cancer and other comorbidities are needed.

Abstract 12885: Sleepless Nights and Squeamish Days: A Conundrum of Recurrent Myocardial Ischemia

A 63-year old Caucasian female with history of aortic valve replacement and CAD with prior drug-eluting stent placement (DES) to proximal LAD and LCX, presented as a hospital transfer with recurrent episodes of chest pain. Chest discomfort was described as severe chest pressure, radiating to bilateral upper extremities. Episodes were not associated with significant exertion and frequently occurred at night/early morning. Of note, the patient had undergone coronary angiography at the outside hospital, revealing no in-stent restenosis or new coronary lesions. Soon after the patient’s arrival in the CCU, she developed profound chest pressure, accompanied by hypotension, diaphoresis and nausea. Her 12-lead ECG revealed 2-mm ST-elevation in aVR, accompanied by ST-depression in inferior, anterior, and apical leads. Initial high-sensitivity (hs)-troponin T was 26 ng/L. She was given sublingual nitroglycerin and was started on a nitroglycerin and nicardipine infusion, with resolution of symptoms after ~30 minutes, followed by normalization of hs-troponin T. A transthoracic echocardiogram did not reveal focal left ventricular (LV) wall motion abnormalities, mild LV hypertrophy was present. Given the patients’ presentation with no in-stent restenosis or new lesions, frequent episodes of chest pain-not related to exertion with occurrence at nighttime and early morning, her presentation was deemed to be consistent with epicardial coronary vasospasm. Subsequently, the patients’ anti-anginal regimen was uptitrated to include extended-release nitrates, calcium-channel blockade, and I Na blockade. Unfortunately, she continued to have frequent episodes of profound angina, accompanied by hypotension, and significant ischemic ECG changes. This prompted us to pursue bilateral sympathectomy. Subsequently, the patient had resolution of prior symptoms. She was continued on an anti-vasospastic regimen, consisting of extended release nitrates and calcium-channel blockade. This case represents the challenging management of medication-resistant epicardial coronary artery vasospasm. As previously described, sympathectomy remains an effective therapeutic option for management in these difficult and life-threatening situations.

Cancer treatment resumption in patients with new-generation drug-eluting stents.

Percutaneous coronary intervention (PCI) with new-generation drug-eluting stents (DESs) may provide survival benefits to the cancer population undergoing PCI by expediting cancer treatment due to improved safety profile. We aimed to assess the safety of starting or resuming cancer treatment within 6 months of DES placement. We also compared the impact of different DES types on the overall survival (OS) in cancer patients and to identify a safe threshold for dual antiplatelet therapy (DAPT) discontinuation. Cancer patients at our institution undergoing PCI with DES from December 2014 to June 2017 were included. Baseline demographics, DAPT duration, malignancy type, stage, and treatment were retrospectively analyzed. Univariate Cox regression was used to pinpoint baseline characteristics that correlated with OS. Survivorship was determined by Kaplan-Meier analysis, and the log-rank test was used to compare OS among DES types. Seventy-five patients were included. Of these, 45 had biodegradable polymer DES (Synergy) and 30 patients had durable polymer DES (Resolute Integrity, Xience, Ion, or Promus). Mean duration of follow-up was 1367 ± 334 days. There were two minor bleeding complications. No statistically significant differences in OS were found among different stent brands. Discontinuation of aspirin, early P2Y12 inhibitor discontinuation, and advanced cancer were significantly associated with OS. DAPT discontinuation <6 months after PCI was not associated with stent thrombosis or in-stent restenosis. There were two major adverse cardiac events: one in-stent restenosis while on DAPT for >12 months (attributed to radiation-induced heart disease) and one myocardial infarction and death. Of patients who resumed or started cancer treatment (chemotherapy, radiation therapy, or surgery) after PCI, all but one did so within 6 months of PCI, and most of them as early as 2 weeks. Patients may resume cancer treatment <6 months after PCI. We suggest that DAPT may be safely interrupted as early as 6 months, but additional longitudinal studies are needed.

Relation between pre-existing plaque size and neointimal healing in an adult porcine model of familial hypercholesterolemia

Abstract Background Despite the efficacy of novel drug eluting stents (DES) in preventing restenosis, this complication still occurs, as do neo-atherosclerosis development and poor stent strut coverage that are associated with stent thrombosis. Safety and efficacy of novel coronary stents are preclinically being tested using an established porcine coronary model. However, the use of young healthy animal only allow limited conclusions to be drawn on the long-term effects, as the artieries do not reflect human pathology of advanced atherosclerosis. A key unresolved question is whether and how the presence, size and composition of pre-existing atherosclerotic plaque affect neointimal healing. Purpose The objective of this study is to understand the role of atherosclerotic plaque in neointimal response following DES placement in a large animal model of coronary artery disease by using optical coherence tomography (OCT) analysis. Methods The study was approved by the animal ethics committee. Familial hypercholesterolemia (FH) swine (n=6 Bretoncelles-Meishan) were given a high fat diet for 12 months to develop atherosclerosis. Stents (n=14) were implanted in n=14 coronary arteries under guidance of OCT with a stent-artery ratio of 1.1:1 at sites of atherosclerotic plaque, and animals were sacrificed after 28 days. Two types of Sirolimus eluting stents with different release profiles were implanted. Serial OCT pullbacks were taken before and after stent placement and after 28 days (follow-up), quantitatively analyzed and compared using dedicated software. The lumen area, stent area, plaque size (calculated as external elastic lamina (EEL) area - lumen area) and neointima (calculated as stent area – lumen area) were evaluated for each frame and averaged per stent. The plaque burden before stent implantation was evaluated at the same site of stent placement using coronary side branches as reference. Results The graph shows the association between the pre-existing plaque size before stenting and neointima formation after 28 days. Surprisingly, more pre-existing plaque size resulted in less neointima (P&amp;lt;0.01). There was one outlier, a stent with long dissection and extensive malapposition at baseline which showed an excessive tissue response at follow-up. The response in this animal model shows similarity to human vessel response as both regions with thin neointima formation as well as poor strut coverage were observed for both stent types. Conclusion The novel model of adult FH swine shows long-term vessel response to DES, that is similar to human response. This work shows that pre-existing atherosclerotic plaque affects the neointima after DES implantation. This insight highlights the necessity to use relevant disease models for safety and efficacy testing. Plaque size and neointima relation Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Netherlands Organisation for Health Research and Development (ZonMw)