Long-term Antiplatelet Therapy Research Articles

Management of Abdominal Aortic Aneurysm Surgery in Glanzmann’s Thrombasthenia Patients with Anti-GPIIb-IIIa Antibodies: A Case Report

Glanzmann’s thrombasthenia (GT) is a rare autosomal recessive disorder of platelet function. The frequent occurrence of alloimmunization due to repeated platelet transfusions is the major complication of the disease. Achieving hemostasis in these patients with anti-GPIIb-IIIa antibodies during surgical procedures is a significant challenge due to the high risk of bleeding. Recombinant activated factor VII (rFVIIa) is an effective agent for achieving hemostasis in alloimmunized Glanzmann’s thrombasthenia patients. The key clinical question was to determine whether abdominal aortic aneurysm surgery can be safely performed with rFVIIa in Glanzmann’s thrombasthenia patients with anti-GPIIb/IIIa antibodies and whether long-term antiplatelet therapy is suitable for these patients. The patient underwent endovascular aneurysm repair with intensive rFVIIa administration, experiencing neither bleeding nor thrombosis. Data regarding the surgical management of Glanzmann’s thrombasthenia patients with anti-GPIIb-IIIa antibodies and the use of antithrombotics in this high-risk population are still very limited. Sharing clinical experience can be valuable for hematologists managing similar cases.

Treatment of thrombotic cardiovascular diseases in people with haemophilia: A Japanese consensus study.

Cardiovascular diseases (CVD) that require long-term anticoagulant and antiplatelet therapy presents a problem in people with haemophilia (PWH) who receive factor replacement therapy to reduce bleeding risk. Currently, there are no Japanese guidelines for the management of PWH with CVD. To develop expert guidance on managing CVD in PWH in Japan. A steering committee of four experts (two haemophilia specialists, one thrombosis specialist, one cardiologist) identified 44 statements related to five key themes. An online questionnaire was produced comprising a mix of 4-point Likert scale and multiple-choice questions that was sent to specialists in the management of PWH with CVD in Japan. Consensus was defined as high or very high if a respective ≥75% or ≥90% of respondents agreed with a statement. Of 16 potential respondents, responses were received from 15 specialists. Of the Likert scale questions, 71% (29/41) achieved ≥90% agreement (very strong agreement), 17% (7/41) achieved 75%-89% agreement (strong agreement) and 15% (6/41) did not achieve consensus agreement. The three multiple-choice questions failed to identify a strong preference. Agreement on specific target trough clotting factor levels for managing certain clinical situations, such as when in the presence of non-valvular atrial fibrillation or myocardial infarction, was also achieved. The results of this consensus study provide a framework for cardiologists and haematologists to manage PWH who are at risk of, or who have, CVD. Implementation of the recommendations provided herein may improve outcomes for PWH with CVD.

Long-term combined antiplatelet therapy for secondary prevention of noncardioembolic stroke

Introduction. The high risk of recurrent ischemic events after non-cardioembolic ischemic stroke(IS), the prevalence of which is 25% of all strokes in the Russian Federation, determines the need to search for effective and safe secondary prevention strategies.Аim. The study was to evaluate the efficacy and safety of a combination of ADP receptor inhibitors (dipyridamole) with acetylsalicylic acid in patients with ischemic stroke (IS) in the secondary prevention of noncardioembolic stroke.Materials and methods. 229 patients in the early recovery period of noncardioembolic IS (139 women, 90 men), with an average age of 59.0 ± 5.7 years were included in the study. The duration of IS was 54.4 ± 6.1 days. All patients received a multimodal medical rehabilitation (MMR) program. Long-term double antiplatelet therapy with acetylsalicylic acid (ASA) 75 mg per day and dipyridamole at a daily dose of 225 mg divided into 3 doses were prescribed to all the patients. The neurological and neuropsychological status of the patient, quality of life and hemorheological parameters were assessed initially (T0), after MMR (T1, 6 weeks) and 12 months after IS(T2).Results. Motor and coordination indicators of patients as well as the cognitive and emotional parameters were significantly (p < 0,05) improved due to MMR technology. These were confirmed by the dynamics of the corresponding scales. The prescribed double antiplatelet therapy did not cause significant adverse events and worsening of the patients’ well-being both during the MMR process and during the observation period. The combination of ASA with dipyridamole was well tolerated. At the end of the study, recurrent IS, myocardial infarctions, and fatal bleeding were not recorded. In 5.2% patients with severe risks of cardiovascular complications there was occurred TIA. The effectiveness of the dual antiplatelet therapy was confirmed by a decrease in the level of platelet aggregation (p < 0,05).Conclusions. The high effectiveness of secondary prevention of IS with a combination of ASA and dipyridamole with good tolerability and safety in patients after IS has been shown.

Clinical Practice Recommendations for Antithrombotic Management of Peripheral Artery Disease: An Indian Perspective

Abstract Currently, there are no guidelines or consensus recommendations on the antithrombotic management of peripheral artery disease (PAD) from an Indian perspective. In this article, we have summarized clinical practice recommendations on antithrombotic management of (i) asymptomatic chronic PAD (cPAD), (ii) symptomatic cPAD (intermittent claudication [IC] and chronic limb-threatening ischemia [CLTI]), and (iii) after revascularization (endovascular and surgical). An electronic search of the PubMed database was undertaken to identify relevant articles. Various combinations of keywords such as PAD, chronic peripheral arterial disease, asymptomatic chronic peripheral arterial disease, symptomatic chronic peripheral arterial disease, dual antiplatelet therapy, single antiplatelet therapy, dual pathway inhibition, antithrombotic, revascularization, endovascular, and surgical were used. Randomized controlled trials, case reports, practice guidelines, systematic literature reviews, and meta-analyses were screened and assessed. A roundtable meeting of experts (n = 13) was conducted to arrive at clinical practice recommendations. Experts made their decisions based on the evidence and guideline recommendations. In patients with asymptomatic cPAD and significant peripheral artery stenosis (PAS), long-term single antiplatelet therapy may be considered at the discretion of the clinician. There is no clear evidence in favor of long-term dual antiplatelet therapy in symptomatic cPAD. Experts agreed that low-dose rivaroxaban plus aspirin should be considered in patients with asymptomatic cPAD with >50% PAS and conditions such as diabetes and polyvascular disease. This combination was also suggested in patients with IC, CLTI, postendovascular (stent based/nonstent), and surgical revascularization to reduce cardiovascular and limb ischemic risk, including major amputation in the absence of high bleeding risk or other contraindications.

Thromboelastography in Long-Term Antiplatelet Therapy for Patients Diagnosed with Benign Prostate Hyperplasia Undergoing Holmium Laser Enucleation of the Prostate: A Retrospective Study.

To compare low- vs high-power HoLEP effects on coagulation in patients on antiplatelet (AP) therapy via thromboelastography (TEG). 210 patients was retrospectively analyzed and stratificated into three discrete groups, specifically: Group A (AP therapy, high-power HoLEP, n = 72); Group B (AP therapy, low-power HoLEP, n=73); Group C (no AP therapy, low-power HoLEP, n = 65). Baseline characteristics and coagulation profiles via TEG were compared. Univariate and multivariate analyses were conducted to identify independent risk factors associated with hematuria. Furthermore, parameters such as IPSS, Qmax, post-void residual volume V2 and PSA levels were recorded during 1year follow-up. No differences in terms of baseline characteristics across all groups. Significant differences were observed in the duration of enucleation, morcellation, bladder irrigation, post-operative catheterization, length of hospital stay and the extent of hemoglobin reduction (F = 54.06, 8.54, 6.68, 9.24, 17.06, 5.97, p <0.05). No differences were noted in postoperative hematuria, urine retention, transfusion rates, and SUI (x1 2 = 1.082 ; x2 2=0.197,; x3 2=3.981;x4 2=0.816, p >0.05). Univariate and multivariate analyses revealed that prostate volume emerged as an independent risk factor for hematuria (OR 1.080, 95% CI: 1.007-1.158, p =0.031). Clinical outcomes including Qmax, IPSS, V2, and PSA demonstrated significant enhancement during 1 year follow-up. Compared to HP-HoLEP, LP-HoLEP effectively reduces surgical and subsequent processing times, decreases hospital stay duration, and diminishes hemoglobin decline, offering a viable option without discontinuing AP therapy.

Effect of chronic antiplatelet therapy on clinical outcomes of endovascular thrombectomy for treatment of acute ischemic stroke.

The objective of this study was to investigate the prognostic significance of chronic antiplatelet therapy (APT) usage in acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT). Long-term APT may enhance recanalization but may also predispose patients to an increased risk of hemorrhagic transformation. Weighted hospitalizations for anterior-circulation AIS treated with EVT were identified in a large United States claims-based registry. Baseline clinical characteristics and outcomes were compared between patients with and without chronic APT usage prior to admission. Multivariable logistic regression analysis was performed to assess adjusted associations between APT and study endpoints. This analysis identified 36,560 patients, of whom 8170 (22.3%) were on a chronic APT regimen prior to admission. These patients were older and demonstrated a higher burden of comorbid disease, but had similar stroke severity on presentation in comparison with those not on APT. On unadjusted analysis, patients with prior APT demonstrated higher rates of favorable outcomes (24.3% vs 21.5%, p < 0.001), lower rates of mortality (7.0% vs 10.1%, p < 0.001), and lower rates of any intracranial hemorrhage (ICH; 20.3% vs 24.2%, p < 0.001), but no difference in rates of symptomatic ICH (sICH). Following multivariable adjustment for baseline clinical characteristics including age, acute stroke severity, and comorbidity burden, prior APT was associated with favorable outcome (adjusted odds ratio [aOR] 1.21, 95% CI 1.17-1.24, p < 0.001) and a lower likelihood of mortality (aOR 0.73, 95% CI 0.70-0.77, p < 0.001), without an increased likelihood of ICH (any ICH aOR 0.84, 95% CI 0.81-0.87, p < 0.001; sICH aOR 0.92, 95% CI 0.82-1.03, p = 0.131). Retrospective evaluation of patients with AIS treated with EVT using registry-based data demonstrated an association of prior APT usage with favorable outcomes, without an increased risk of hemorrhagic transformation.

Endoluminal flow diversion as a primary treatment strategy for pediatric traumatic intracranial aneurysms: a case-based review of literature.

Traumatic intracranial aneurysms (TICAs) constitute a notable portion of pediatric intracranial aneurysms. Their unstable structure dictates a high incidence of rupture or mass effect from enlarging unruptured aneurysms, necessitating prompt diagnosis and treatment. TICAs often lack a true neck or are wide-necked, making them unsuitable for coil embolization and surgical clipping, and their fragile nature poses a risk of rupture during surgical and intrasaccular interventions. Endoluminal flow diverters (FD), deployed without requiring direct access to the aneurysmal sac, have emerged as an appealing sole treatment modality for TICAs. However, the clinical experience with this technique remains limited in the pediatric population. We describe the successful treatment of a paraclinoid TICA in a 4-year-old female using an endoluminal FD alone. Additionally, we conducted a literature review to assess the safety and effectiveness of this treatment modality in pediatric TICAs. Endoluminal flow diversion led to complete aneurysm obliteration in our case, with no observed complication, at the 9-month follow-up. Our review of the previously reported pediatric TICAs managed by standalone flow diversion highlights this technique as safe, efficient, and promising as a sole treatment modality, particularly in the anterior circulation, with a high rate of persistent total obliteration and a low rate of complications. However, the requirement for long-term antiplatelet therapy with the possibility of frequent dose monitoring and adjustments warrants special attention when using endoluminal FDs. Until guidelines specifically addressing optimal antiplatelet therapy in children with intracranial FDs are formulated, adherence to existing protocols is imperative to avoid in-stent thrombosis. Our literature review and personal experience indicate that endoluminal flow diversion can be a viable treatment approach for pediatric TICAs. However, prospective studies with extensive follow-ups are required to assess the durability of endoluminal FDs in treating pediatric TICAs, considering the long life expectancy of this demographic.

Long-term antiplatelet therapy in patients with high risk of stroke

Diseases associated with atherosclerosis occupy a leading place among the causes of death in most countries of the world. Antiplatelet therapy is one of the most eff ective and promising methods of stroke prevention. Long-term use of platelet antiplatelet agents of various pharmaceutical groups in high-risk patients has become a daily clinical practice. As a result of the practical application of modern drug strategies, the life expectancy of stroke survivors is increasing. The average age of patients with cardiovascular pathology is increasing. The majority of patients receiving antiplatelet agents are over 70 years old. The number of patients continuously receiving antiplatelet agents for 10 years or more is already hundreds of thousands. In recent years, clinical guidelines have expanded the indications for the appointment of platelet antiplatelet agents of diff erent pharmaceutical groups. In neurology, clopidogrel, ticagrelor, cilostazol are allowed. However, the choice of the optimal treatment regimen in patients with cerebrovascular pathology often causes diffi culty for doctors. Standard treatment regimens for patients at high risk of stroke are based on the use of acetylsalicylic acid preparations. In some cases, patients receive a combination of antiplatelet agents: aspirin and dipyridamole. The author analyzes the results of 30 years of acetylsalicylic acid use in a patient with a high risk of thrombosis and bleeding. During this period, the patient suff ers a transient ischemic attack, ischemic stroke, hemorrhoidal bleeding and intracranial hemorrhage. The article discusses optimal solutions in choosing an antithrombotic strategy in patients with high risk of stroke on a clinical example. Based on the analysis of current clinical recommendations and scientifi c research, the article formulates the principles of long-term antiplatelet therapy for patients of older age groups with the need for long-term treatment. The main directions of diff erentiated antithrombotic therapy have been determined depending on the suspected pathogenetic subtype of ischemic stroke, the risk of bleeding, age and the expected duration of treatment.

Revascularization and Left Ventricular Dysfunction for ICD Eligibility.

Common triggers for sudden cardiac death (SCD) are transient ischemia, hemodynamic fluctuations, neurocardiovascular influences, and environmental factors. SCD occurs rapidly when sinus rhythm degenerates into ventricular tachycardia (VT) and/or ventricular fibrillation (VF), followed by asystole. Such progressive worsening of the cardiac rhythm is in most cases observed in the setting of ischemic heart disease and often associated with advanced left ventricular (LV) impairment. Revascularization prevents negative outcomes including SCD and heart failure (HF) due to LV dysfunction (LVD). The implantable cardioverter-defibrillator (ICD) on top of medical therapy is superior to antiarrhythmic drugs for patients with LVD and VT/VF. The beneficial effects of ICD have been demonstrated in primary prevention of SCD as well. However, yet debated is the temporal management for patients with LVD who are eligible to ICD prior to revascularization, either through percutaneous or surgical approach. Restoration of coronary blood flow has a dramatic impact on adverse LV remodeling, while it requires aggressive long-term antiplatelet therapy, which might increase complication for eventual ICD procedure when percutaneous strategy is pursued; on the other hand, when LV and/or multiorgan dysfunction is present and coronary artery bypass grafting is chosen, the overall risk is augmented, mostly in HF patients. The aims of this review are to describe the pathophysiologic benefits of revascularization, the studies addressing percutaneous, surgical or no revascularization and ICD implantation, as well as emerging defibrillation strategies for patients deemed at transient risk of SCD and/or at higher risk for transvenous ICD implantation.

Balloon Angioplasty for Symptomatic Intracranial Artery Stenosis (BASIS): protocol of a prospective, multicentre, randomised, controlled trial

BackgroundThe superiority of balloon angioplasty plus aggressive medical management (AMM) to AMM alone for symptomatic intracranial artery stenosis (sICAS) on efficacy and safety profiles still lacks evidence from randomised controlled...

Evaluation of the safety and efficacy of a Polyzene-F nanocoated coronary stent system: A systematic review and single-arm meta-analysis.

A stent for patients with coronary heart disease (CHD) provides a requirement for a long-term antiplatelet therapy because of the high possibility of the development of stent thrombosis. It was against this background that both Cobra and Catania Polyzene-F (PzF) stents were designed to reduce the occurrence of stent thrombosis (ST). In this study, we review the safety and effectiveness of a PzF-nanocoated stent. This systematic review with the title was registered in PROSPERO (No.398781). The inclusion criteria were including studies among patients with PzF-nanocoated coronary stents and reported target vessel failure (TVF) and ST as the outcomes, and the exclusion criteria were excluding reported patients who could not receive the adjunctive medical therapies or without the necessary endpoints. Reports about PzF-nanocoated stents were searched in PubMed, Embase, and Web of Science and other sources. Because of the existence of few reports and a lack of comparison groups, a single-arm meta-analysis was conducted in R software (v3.6.2), using a random-effects model with the generic inverse variance method. After a heterogeneity test, assessment of evidence quality was conducted by using GRADE software. A funnel plot Egger's test was performed to evaluate publication bias, and a sensitivity analysis was done to determine the robustness of the overall effects. Six studies of 1,768 subjects were included. The primary endpoint that pooled the TVF rate was 8.9% (95% CI 7.5%-10.2%), which comprised the pooled cardiac death (CD) rate (1.5%, 95% CI 0%-3%), myocardial infarction (MI) rate (2.7%, 95% CI 0.4%-5.1%), target vessel revascularization (TVR) (4.8%, 95% CI 2.4%-7.2%), or target lesion revascularization (TLR) (5.2%, 95% CI 4.2%-6.4%), while the secondary endpoint ST was 0.4% (95% CI 0.1%-0.9%). The funnel plots of TVF, CD, TVR, and TLR did not show any serious publication bias, and TVF, TVR, and TLR showed evidence of moderate quality in GRADE assessment. The sensitivity analysis showed that TVF, TLR, and ST exhibited good stability (I 2 = 26.9%, 16.4%, and 35.5%, respectively), while the other endpoints showed moderate instability. These data indicated that the PzF-nanocoated coronary stents of the Cobra and Catania systems demonstrated good safety and efficacy in clinical application. However, the sample size of patients included in the reports was relatively small, and this meta-analysis will be updated if more studies are published in the future. https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42023398781.

Small-vessel disease in the brain

Cerebral small-vessels are generally located in the brain at branch points from major cerebral blood vessels and perfuse subcortical structures such as the white matter tracts, basal ganglia, thalamus, and pons. Cerebral small-vessel disease (CSVD) can lead to several different clinical manifestations including ischemic lacunar stroke, intracerebral hemorrhage, and vascular dementia. Risk factors for CSVD overlap with conventional vascular risk factors including hypertension, diabetes mellitus, and hypercholesterolemia, as well as genetic causes. As in cardiovascular disease, treatment of CSVD involves both primary and secondary prevention. Aspirin has not been established as a primary prevention strategy for CSVD among the general population; however, long-term antiplatelet therapy with aspirin alone continues to be the mainstay of secondary stroke prevention for non-cardioembolic ischemic stroke and high-risk TIA.

European Stroke Organisation (ESO) Guidelines on Moyamoya angiopathy Endorsed by Vascular European Reference Network (VASCERN).

The European Stroke Organisation (ESO) guidelines on Moyamoya Angiopathy (MMA), developed according to ESO standard operating procedure and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology, were compiled to assist clinicians in managing patients with MMA in their decision making. A working group involving neurologists, neurosurgeons, a geneticist and methodologists identified nine relevant clinical questions, performed systematic literature reviews and, whenever possible, meta-analyses. Quality assessment of the available evidence was made with specific recommendations. In the absence of sufficient evidence to provide recommendations, Expert Consensus Statements were formulated. Based on low quality evidence from one RCT, we recommend direct bypass surgery in adult patients with haemorrhagic presentation. For ischaemic adult patients and children, we suggest revascularization surgery using direct or combined technique rather than indirect, in the presence of haemodynamic impairment and with an interval of 6-12 weeks between the last cerebrovascular event and surgery. In the absence of robust trial, an Expert Consensus was reached recommending long-term antiplatelet therapy in non-haemorrhagic MMA, as it may reduce risk of embolic stroke. We also agreed on the utility of performing pre- and post- operative haemodynamic and posterior cerebral artery assessment. There were insufficient data to recommend systematic variant screening of RNF213 p.R4810K. Additionally, we suggest that long-term MMA neuroimaging follow up may guide therapeutic decision making by assessing the disease progression. We believe that this guideline, which is the first comprehensive European guideline on MMA management using GRADE methods will assist clinicians to choose the most effective management strategy for MMA.

Antithrombotic treatment after stroke due to intracerebral haemorrhage.

Antithrombotic treatment after stroke due to intracerebral haemorrhage.

Outcomes associated with antithrombotic strategies in heart failure with reduced ejection fraction and sinus rhythm following acute ischemic stroke.

Insufficient data exist regarding the benefit of long-term antiplatelet vs. anticoagulant therapy in the prevention of recurrent ischemic stroke in patients with ischemic stroke and heart failure with reduced ejection fraction (HFrEF). Therefore, this study aimed to compare longitudinal outcomes associated with antiplatelet vs. anticoagulant use in a cohort of patients with stroke and with an ejection fraction of ≤40%. We retrospectively analyzed single-center registry data (2015-2021) of patients with ischemic stroke, HFrEF, and sinus rhythm. Time to the primary outcome of recurrent ischemic stroke, major bleeding, or death was assessed using the adjusted Cox proportional hazards model and was compared between patients treated using anticoagulation (±antiplatelet) vs. antiplatelet therapy alone after propensity score matching using an intention-to-treat (ITT) approach, with adjustment for residual measurable confounders. Sensitivity analyses included the multivariable Cox proportional hazards model using ITT and as-treated approaches without propensity score matching. Of 2,974 screened patients, 217 were included in the secondary analyses, with 130 patients matched according to the propensity score for receiving anticoagulation treatment for the primary analysis, spanning 143 patient-years of follow-up. After propensity score matching, there was no significant association between anticoagulation and the primary outcome [hazard ratio (HR) 1.10, 95% confidence interval (CI): 0.56-2.17]. Non-White race (HR 2.26, 95% CI: 1.16-4.41) and the presence of intracranial occlusion (HR 2.86, 95% CI: 1.40-5.83) were independently associated with the primary outcome, while hypertension was inversely associated (HR 0.42, 95% CI: 0.21-0.84). There remained no significant association between anticoagulation and the primary outcome in sensitivity analyses. In HFrEF patients with an acute stroke, there was no difference in outcomes of antithrombotic strategies. While this study was limited by non-randomized treatment allocation, the results support future trials of stroke patients with HFrEF which may randomize patients to anticoagulation or antiplatelet.

Retrospective analysis of image characteristics of 76 cases of cerebral vascular fenestrations.

This study aims to summarize the clinical and imaging features of cerebral vascular fenestration and to explore the association between cerebral vascular fenestration and cerebral infarction and aneurysm. The computed tomography angiography (CTA), magnetic resonance angiography (MRA), and digital subtraction angiography (DSA) imaging data of 76 cases of cerebral vascular fenestration from January 2021 and December 2021 in the Yantai Yuhuangding Hospital Affiliated to Qingdao University were analyzed. The general information was described. The location, morphology, and size of cerebral vascular fenestration were described. The association between cerebral vascular fenestration and infarction and aneurysm was analyzed. Among 76 patients, a total of 80 fenestrations were detected (two patients had three fenestrations), and basilar artery fenestration was the most common (28/80). The fenestration <5 mm was 43/80, 5-10 mm was 12/80, and ≥10 mm was 25/80. Moreover, 19 patients had other vascular diseases: 10 with aneurysms, 5 with moyamoya diseases, and 4 with cerebral artery dissections. Except for one aneurysm at the site of the fenestration, other aneurysms were separate from the fenestrations. In addition, 37 patients had cerebral infarctions, of which 16 had cerebral infarctions in the blood supply area of the arterial fenestration. Among these 16 patients, there was more cerebral infarction in posterior circulation than in anterior circulation. However, no statistically significant differences were detected in the risk factors between the fenestration-relevant cerebral infarctions group and the non-fenestration-relevant cerebral infarctions group. In our study, cerebral vascular fenestration occurred most frequently in the basilar artery and may be combined with other vascular diseases. Fenestration in posterior circulation may be related to cerebrovascular diseases. Nonetheless, no clear clinical relevance was observed between fenestration and cerebral infarction. Also, we did not find a definite association between fenestration and aneurysm. For fenestration patients with cerebral infarctions, long-term antiplatelet and statin therapy may be safe and effective.

Perioperative Management of Antiplatelet Therapy: A Systematic Review and Meta-analysis.

ObjectiveTo summarize the available evidence about the perioperative management of patients who are receiving long-term antiplatelet therapy and require elective surgery/procedures.MethodsThis systematic review supports the development of the American College of Chest Physicians guideline on the perioperative management of antiplatelet therapy. A literature search of MEDLINE, EMBASE, Scopus and Cochrane databases was conducted from each database’s inception to July 16, 2020. Meta-analyses were conducted when possible.ResultsIn patients receiving long-term antiplatelet therapy and undergoing elective noncardiac surgery, the available evidence did not show a significant difference in major bleeding between a shorter vs longer antiplatelet interruption, with low certainty of evidence (COE). Compared with patients who received placebo perioperatively, aspirin continuation was associated with increased risk of major bleeding (relative risk [RR], 1.31; 95% CI, 1.15-1.50; high COE) and lower risk of major thromboembolism (RR, 0.74; 95% CI, 0.58-0.94; moderate COE). During antiplatelet interruption, bridging with low-molecular-weight heparin was associated with increased risk of major bleeding compared with no bridging (RR, 1.86; 95% CI, 1.24-2.79; very low COE). Continuation of antiplatelets during minor dental and ophthalmologic procedures was not associated with a statistically significant difference in the risk of major bleeding (very low COE).ConclusionThis systematic review summarizes the current evidence about the perioperative management of antiplatelet therapy and highlights the urgent need for further research, particularly with the increasing prevalence of patients taking 1 or more antiplatelet agents.

Endovascular treatment of aneurysms of the paraophthalmic segment of the internal carotid artery: Current status.

The paraophthalmic segment of the internal carotid artery (ICA) originates from the distal border of the cavernous ICA and terminates at the posterior communicating artery. Aneurysms arising from the paraophthalmic segment represent ~5–10% of intradural aneurysms. Due to the advent of endovascular treatment (EVT) techniques, specifically flow-diverting stents (FDSs), EVT has become a good option for these aneurysms. A literature review on EVT for paraophthalmic segment aneurysms is necessary. In this review, we discuss the anatomy of the paraophthalmic segment, classification of the paraophthalmic segment aneurysms, EVT principle and techniques, and prognosis and complications. EVT techniques for paraophthalmic segment aneurysms include coil embolization, FDSs, covered stents, and Woven EndoBridge devices. Currently, coiling embolization remains the best choice for ruptured paraophthalmic segment aneurysms, especially to avoid long-term antiplatelet therapy for young patients. Due to the excessive use of antiplatelet therapy, unruptured paraophthalmic segment aneurysms that are easy to coil should not be treated with FDS. FDS is appropriate for uncoilable or failed aneurysms. Other devices cannot act as the primary choice but can be useful auxiliary tools. Both coiling embolization and FDS deployment can result in a good prognosis for paraophthalmic segment aneurysms. The overall complication rate is low. Therefore, EVT offers promising treatments for paraophthalmic segment aneurysms. In addition, surgical clipping continues to be a good choice for paraophthalmic segment aneurysms in the endovascular era.

Results of Temporary Stent-assisted Coil Embolization (CATS) for the Treatment of Wide-neck Aneurysms

PurposeIn intracranial wide-neck aneurysms, simple coil embolization is often not a feasible treatment option. Balloon-assisted coiling comes with the drawback of blood flow impairment, whereas permanent stent placement requires long-term antiplatelet therapy. Temporary stent-assisted coiling (coiling assisted by temporary stenting, CATS) is an alternative that eliminates both disadvantages. Because prior studies included only small numbers of patients, it was our aim to analyze the safety and effectiveness of this technique in a larger cohort of patients.MethodsWe retrospectively evaluated all endovascular aneurysm treatments at our institution from 2011 to 2020. Out of a total of 688 aneurysm treatments, we intended to perform 95 (14%) with temporary stent-assisted coiling and included them in our study.ResultsSixty-four (64)% of aneurysms were acutely ruptured, 3% were symptomatic but unruptured, and 33% were incidental. Successful stent recovery was possible in 93% of treatments. Initial complete and adequate occlusion rate were 53% and 82%, respectively. Long-term follow-up at 6 and 12 months was available for 71% and 44% of cases. Aneurysm recurrence was observed in 10% of cases after 6 months, and in 17% after 1 year or later. Periprocedural complications were noted in 12 cases (13%), of which only 1 complication was definitely associated with temporary stent-assisted coiling (1%). One of the periprocedural complications resulted in neurological damage, the other complications were asymptomatic.ConclusionTemporary stent-assisted coiling appears to be a safe and effective treatment method in intracranial wide-neck aneurysms. Procedural safety appears to be comparable with balloon remodeling or permanent stent-assisted coiling, but it comes with the further benefit of diminished need for posttreatment antiplatelet therapy, which may improve the outcome of patients. However, to define the true value and potential benefit of this technique, further prospective studies are required.

Secretory SERPINE1 Expression Is Increased by Antiplatelet Therapy, Inducing MMP1 Expression and Increasing Colon Cancer Metastasis.

Contrary to many reports that antiplatelet agents inhibit cancer growth and metastasis, new solid tumors have been reported in patients receiving long-term antiplatelet therapy. We investigated the effects of these agents directly on cancer cells in the absence of platelets to mimic the effects of long-term therapy. When four antiplatelet agents (aspirin, clopidogrel, prasugrel, and ticagrelor) were administered to colon cancer cells, cancer cell proliferation was inhibited similarly to a previous study. However, surprisingly, when cells were treated with a purinergic P2Y12 inhibitor (purinergic antiplatelet agent), the motility of the cancer cells was significantly increased. Therefore, gene expression profiles were identified to investigate the effect of P2Y12 inhibitors on cell mobility, and Serpin family 1 (SERPINE1) was identified as a common gene associated with cell migration and cell death in three groups. Antiplatelet treatment increased the level of SERPINE1 in cancer cells and also promoted the secretion of SERPINE1 into the medium. Increased SERPINE1 was found to induce MMP1 and, thus, increase cell motility. In addition, an increase in SERPINE1 was confirmed using the serum of patients who received these antiplatelet drugs. With these results, we propose that SERPINE1 could be used as a new target gene to prevent the onset and metastasis of cancer in patients with long-term antiplatelet therapy.