Need For Dual Antiplatelet Therapy Research Articles

Clinician perspectives regarding CYP2C19 genotype testing in patients with critical limb ischemia: A Delphi approach.

Antiplatelet therapy is an essential element in the management of patients with arterial vascular disease. In peripheral arterial disease (PAD), dual antiplatelet therapy (DAPT), primarily clopidogrel and aspirin, is routinely prescribed following intervention. There is sparse data regarding the need for DAPT, the appropriate duration, or the heterogeneity of treatment effects for antiplatelet regimens across patients, leading to potential uncertainty and heterogeneity around treatment practices. An example of heterogeneity of treatment effects is a patients' metabolizer status for the use of clopidogrel. The aim of the study was to (1) assess clinicians' knowledge of and attitudes toward managing patients with CYP2C19 mutations, (2) identify barriers to implementation of CYP2C19 testing and management policies, and (3) reach consensus for CYP2C19 testing and management strategies for patients with PAD who undergo peripheral vascular interventions (PVI). A modified Delphi method was used to establish consensus amongst PAD interventionalists around CYP2C19 testing. All practicing Yale New Haven Hospital PAD interventionalists with backgrounds in interventional cardiology, vascular surgery, or interventional radiology were approached by email for participation. Round 1 included the collection of baseline demographic questions, knowledge questions, and three statements for consensus. Knowledge questions were rated on a 0-10 Likert scale with the following anchors: 0 ("Not at all"), 5 ("Neutral), and 10 ("Very Much"). Participants were asked to rate the importance of the three consensus statements on a 9-point Likert scale from 1 ("Strongly Disagree") to 10 ("Strongly Agree"). In Round 2, participants were shown the same consensus statements, the median response of the group from the previous round, and their previous answers. Participants were instructed to revise their rating using the results from the previous round. This process was repeated for Round 3. Of the 28 experts invited to participate, 13 agreed (46%). Participants were predominantly male (92.3%) and white (61.5%) with representation from interventional cardiology (46.2%) and vascular surgery (53.8%). Most participants reported more than 10+ years in practice (61.5%). PAD interventionalists felt they would benefit from more education regarding CYP2C19 mutations (median score 8.0, interquartile range 5.0-8.5). They indicated some familiarity with CYP2C19 mutations (7.0, 6.0-9.5) but did not feel strongly that CYP2C19 was important to their practice (6.0, 5.5-7.5). In each round, the median responses for the three consensus statements were 5, 6, and 9, respectively. With each successive round the interquartile range narrowed indicative of evolving consensus but did not reach the prespecified interquartile range for consensus of 1 for any of the statements. PAD interventionalists practicing at an academic health system recognize the heterogenous response of their patients to clopidogrel therapy but are unsure when to leverage genetic testing to improve outcomes for their patients. Our study identified gaps regarding PAD interventionalists' knowledge, perceived barriers, and attitudes toward CYP2C19 testing in PAD. This information highlights the need for randomized data on genetic testing for clopidogrel responsiveness in peripheral vascular disease following intervention to help guide antiplatelet management.

Y-Stent Technique Using Dual Comaneci Embolization Assist Devices for Coil Embolization of a Ruptured Wide-Necked Anterior Communicating Artery Aneurysm: A Technical Case Report.

Despite technological advances, ruptured wide-necked aneurysms continue to pose a challenge for endovascular management. Comaneci (Rapid Medical) is a relatively new temporary aneurysm neck bridging device to assist in coiling of wide-necked aneurysms without the need for dual antiplatelet therapy or parent vessel flow interruption. Y configuration is often necessary to prevent coil migration in cases of wide-necked aneurysms. Thus far, there have been no reports of using Comaneci device in Y configuration to aid anterior circulation aneurysm treatment. A 60-year-old man presented with a Hunt-Hess grade 5, modified Fisher grade 4 subarachnoid hemorrhage from a ruptured wide-necked anterior communicating artery aneurysm with a dome-to-neck ratio of 1:2. Two Comaneci devices were used in a Y configuration to prevent coil prolapse into the contralateral A2 branch. After successful coiling of the aneurysm, both Comaneci devices were collapsed and removed without incident; the coil catheter was also removed without incident. Follow-up angiogram demonstrated successful occlusion of the wide-necked anterior communicating artery aneurysm without the use of a permanent stent or balloon assistance. This case represents a first-time report of successfully using 2 Comaneci devices in a Y configuration for the treatment of a ruptured wide-necked anterior circulation aneurysm. This knowledge can potentially further expand the use of double Comaneci devices in Y configuration for the treatment of both anterior and posterior circulation aneurysms.

Embolization of a pseudoaneurysm of the innominate artery with a Woven EndoBridge (WEB) device.

The Woven EndoBridge (WEB) is an intra-aneurysmal flow disruptor designed for the treatment of broad-based arterial aneurysms with a high safety and effectiveness profile.1, 2 It does not require concomitant antiplatelet therapy compared to other devices such as flow diverters or intracranial stents. Innominate artery pseudoaneurysms are a rare consequence of blunt traumatic injury, infection, or atherosclerotic disease.3, 4 We describe the case of an innominate artery pseudoaneurysm successfully treated with a WEB SL device instead of stenting, therefore alleviating the need for dual antiplatelet therapy. The treatment was successful and uneventful and postprocedural computed tomography angiography confirmed the complete occlusion of the pseudoaneurysm.

Periprocedural management of ruptured blister aneurysms treated with pipeline flow diversion.

Blister aneurysms are high-risk intracranial vascular lesions. Definitive treatment of these lesions has been challenging. Severe disability or mortality rates are as high as 55% when these lesions are treated with open surgery. Recent data show that flow diversion is a safe and effective alternative treatment for blister aneurysms. Rerupture of the functionally unsecured lesion remains a concern as flow diversion does not immediately exclude the aneurysm from the circulation. A retrospective review was performed of any patients with ruptured blister aneurysms treated with a pipeline embolization device between 2010 and 2020 at the University of Colorado. In this paper, we present the results of the intensive care management of ruptured intracranial blister aneurysms after flow-diverting stent placement. Despite the need for dual antiplatelet therapy and the delayed occlusion of blister aneurysms treated with flow diversion, we did not find an increase in periprocedural complications.

Spontaneous Coronary Artery Dissection in Clinical Practice: Pathophysiology and Therapeutic Approaches.

Spontaneous coronary artery dissection (SCAD) is a cause of myocardial infarction without obstructive coronary artery disease (MINOCA). It is determined by a coronary artery wall layers separation, which occurs regardless of traumatic or iatrogenic injuries. Even if it is often a missed diagnosis, its incidence is growing along with the improvement of intracoronary imaging techniques that allow for better detection. The main angiographical classification distinguishes three different forms, with slightly different prognoses at long-term follow up. SCAD is a recurrent condition, severely hampering the life quality of affected patients. The predominantly young age of patients with SCAD and the high prevalence of females among them have made the topic increasingly important, especially regarding therapeutic strategies. According to the data, the most recommended treatment is conservative, based on the use of antiplatelet agents and supportive anti-ischemic therapy. However, there are conflicting opinions concerning the need for dual antiplatelet therapy and its duration. In the case of invasive treatment, the choice between percutaneous coronary intervention and coronary artery bypass graft depends on the patient's clinical stability and the interested vessel. The purpose of the current review is to revise the pathophysiological mechanisms underlying SCAD and the current knowledge of its treatment.

A novel noble metal stent coating reduces in vitro platelet activation and acute in vivo thrombosis formation: a blinded study

Inherent to any stenting procedure is the prescription of dual antiplatelet therapy (DAPT) to reduce the platelet response. Clinical guidelines recommend 6–12 months of DAPT, depending on stent type, clinical picture and patient factors. Our hypothesis is that a nanostructured noble metal coating has the potential to reduce protein deposition and platelet activation. These effects would reduce subsequent thrombo-inflammatory reactions, potentially mitigating the need for an extensive DAPT in the acute phase. Here, a noble metal nanostructure coating on stents is investigated. Twelve pigs underwent endovascular implantation of coated and non-coated stents for paired comparisons in a blinded study design. The non-coated control stent was placed at the contralateral corresponding artery. Volumetric analysis of angiographic data, performed by a treatment blinded assessor, demonstrated a significant thrombus reduction for one of the coatings compared to control. This effect was already seen one hour after implantation. This finding was supported by in vitro data showing a significant reduction of coagulation activation in the coated group. This novel coating shows promise as an implant material addition and could potentially decrease the need for DAPT in the early phases of stent implementation.

Longitudinal healing flow diverting stents with phosphorylcholine surface modification

BackgroundFlow diversion has become a standard treatment for cerebral aneurysms. However, major drawbacks include the need for dual antiplatelet therapy after implant and delayed complete occlusion of the aneurysm, which...

Rescue stenting after artery occlusion as a complication of an intrasaccular device-assisted coiling embolization: illustrative case.

Endovascular embolization of wide-necked aneurysms can be challenging. The development of intrasaccular devices like the Contour has enabled us to approach these aneurysms effectively by reducing recanalization rates and eliminating the need for dual antiplatelet therapy, which is particularly beneficial in the case of ruptured aneurysms. Although complications from using these devices are rare, it is crucial to address them properly. In this case, the authors highlight how to manage artery thrombosis caused by device protrusion during aneurysm embolization. This report describes a complication in a male patient with a ruptured anterior communicating artery wide-necked aneurysm. Following Contour-assisted coiling of the aneurysm, a realignment of the detachable apex of the device occluded the A2 segment of the right anterior cerebral artery. After the failure of intra-arterial and intravenous tirofiban infusion as well as mechanical thrombectomy, a self-expanding open-cell stent was deployed in the involved vessel, achieving successful reperfusion. The Contour device has a detachable zone that can cause occlusion of the parent vessel after deployment. The use of a stent as a rescue maneuver may be useful if reperfusion of the vessel cannot be achieved through other methods such as aspiration or full-dose antiplatelet therapy.

Abstract Number ‐ 199: Acute Treatment of Aneurysmal Subarachnoid Patients with Flowdiversion: A Single Center Real World Experience

Introduction Subarachnoid hemorrhage patients presenting with complex morphology, and those with dissecting /fusiform aneurysms, blister aneurysms have historically posed a challenge for acute endovascular treatment. Flow diversion as a treatment for ruptured intracranial aneurysms is a last resort given the need for dual antiplatelet therapy in the acute setting. Methods We present our single center experience, real world experience in the acute treatment of patients with subarachnoid hemorrhage with pipeline flow diversion device. Results 6 patients presented acutely with a subarachnoid hemorrhage. Two of those had saccular intracranial aneurysms, 1 with a blister aneurysm, and 3 with dissecting aneurysms. 1 patient presented with a ruptured anterior choroidal artery location dissecting aneurysm, 1 with PCA blister aneurysm, 1 with intradural vertebral artery dissecting aneurysm, 1 saccular posterior communicating artery aneurysm, and another with a ruptured complex morphology anterior choroidal artery aneurysm, and 1 with dissecting PCA aneurysm. All patients were emergently loaded with dual antiplatelet therapy consisting of either aspirin and clopidogrel, or aspirin and ticagrelor or pletal and ticagrelor. 1 patient was treated with surface modified pipeline device with shield technology. Technical success was achieved in 100% of these patients. No acute in stent thrombosis was seen in this cohort. Four patients had no residual filling or recurrence at the 1st follow‐up at a median interval of 2–12 months. 1 patient died from fulminant vaso spasm. Follow‐up is pending in 1 patient. Conclusions In carefully selected patients, flow diversion in the acute setting is tolerated and can be an alternative treatment strategy with an acceptable safety profile.

508 ELIGIBILITY TO DUAL PATHWAY INHIBITION THERAPY IN PATIENTS WITH CORONARY OR PERIPHERAL ARTERY DISEASE

Abstract Background The VOYAGER PAD and COMPASS trials established the benefit of dual pathway inhibition (DPI) with aspirin and low dose rivaroxaban for eligible patients with peripheral artery disease (PAD) undergoing revascularisation and for those with PAD or chronic coronary syndromes (CCS), respectively. However, in-hospital implementation of DPI remains slow in clinical practice, also due to eligibility uncertainties. Purpose To assess the eligibility to DPI among contemporary patients hospitalised in cardiology and vascular surgery units, and to evaluate clinical outcomes of patients presenting with revascularised PAD according to their eligibility to the DPI strategy. Methods We analysed data from patients with revascularised PAD included in the prospective institutional RAPID (RivAroxaban for PerIpheral artery Disease) and applied the VOYAGER PAD criteria to identify patients eligible to DPI and the frequency and distribution of exclusion criteria. Clinical outcomes were compared between patients eligible and not eligible to DPI. The primary efficacy outcome was the composite of cardiovascular death, acute limb ischemia, or unplanned limb revascularization, while the primary safety outcome was major bleeding according to the Bleeding Academic Research Consortium definition (i.e., type 3 or 5). Secondary outcomes included the individual components of the primary efficacy outcome, all-cause death, clinically relevant bleeding and minor bleeding. Finally, to explore the residual potential for DPI applicability in clinical practice, COMPASS criteria were also applied to a contemporary CCS cohort from the institutional registry enrolling coronary artery disease patients undergoing invasive management, and the frequency and characteristics of DPI eligibility between PAD and CCS were compared. Results From May 2021 to August 2022, 122 patients (mean age 70.9±10.1 years, 74.6% male) were included in the RAPID registry. Based on VOYAGER PAD eligibility criteria, 62 patients (50.8%) were eligible to DPI. Main reasons for exclusion were oral anticoagulation (13.1%), prior stroke or transient ischemic attack (11.5%), high bleeding risk (46.7%), or concurrent indications for dual antiplatelet therapy (0.8%). In the CCS registry, 1,389 patients were enrolled in the same period (mean age 70.3±10.5 years, 75.6% male). CCS patients who were eligible to DPI were 276 (19.9%). Main reasons for exclusion were concurrent need for dual antiplatelet therapy (27.1%), high bleeding risk (44.8%), need for oral anticoagulation (21.4%), severe heart failure (9.9%), absence of CAD or PAD (35.3%), and end-stage renal disease (2.6%). To provide updated follow-up information, clinical outcomes will be made available for presentation on December 2022. Conclusions Approximately one patient out of two with revascularised PAD and only one fifth of patients with CCS undergoing invasive management were eligible to DPI. According to these results, unlike candidates to the VOYAGER PAD strategy, candidates to the COMPASS strategy are more likely to be identified in an outpatient than hospital setting.

A Prospective Study of Apixaban for Central Venous Catheter Associated Upper Extremity Deep Vein Thrombosis in Cancer Patients: Catheter 3

Introduction Upper extremity deep vein thrombosis (UEDVT) represents up to 10% of cases of venous thromboembolism (VTE) and is frequently associated with central venous catheter (CVC) placement in patients receiving chemotherapy for cancer. UEDVT may be treated with low molecular weight heparin (LMWH) either as monotherapy or subsequently transitioned to warfarin as we have previously shown (Kovacs 2007). In the Catheter 2 Study (Davies 2018) we showed that Rivaroxaban had efficacy but in the 70 patients that were included there were 6 major bleeds (8.6%) and 1 death due to pulmonary embolism (PE). Given these findings we decided to evaluate the safety and efficacy of Apixaban in the treatment of UEDVT secondary to CVC in patients with cancer. Methods We conducted a prospective cohort study at 3 centres in Canada between May 2017 and December 2021. We enrolled patients ≥18 years of age with active malignancy and symptomatic proximal UEDVT (axillary or more proximal) with or without PE, associated with a CVC. Exclusion criteria included dialysis catheters, active bleeding, platelet count <75 x 109/L, creatinine clearance <30 mL/min, PE with hemodynamic instability, inability to infuse through the catheter after a trial of intraluminal thrombolytic therapy (tissue plasminogen activator, tPa), patients with acute leukemia, patients with multiple myeloma awaiting bone marrow transplant within 3 months, thrombosis involving the brachial, basilic or cephalic veins only, treatment for >7 days with other anticoagulants, need for dual antiplatelet therapy (recent stent), or concomitant use of P-glycoprotein and CYP3A4 inhibitors. The primary objective was to estimate catheter survival at 3 months (defined as a catheter that did not develop infusion failure not responding to 2 mg of tPa). Secondary outcomes included recurrence of DVT, PE, major bleeding, clinically relevant non-major bleeding (CRNMB) and death. All events were independently adjudicated. Due to the fact that in the Catheter 2 Study most bleeds occurred while taking 15 mg bid of Rivaroxaban, for this study, patients were treated with dalteparin, 200 IU/kg x 7days followed by Apixaban 5 mg po bid to complete 12 weeks. tPa for management of blocked lines was allowed. Patients were followed clinically for 12 weeks to assess for clinical events including recurrent symptomatic VTE, major bleeding and CRNMB. Results We included 70 patients (41, 59% women) with a mean age of 62 years. DVTs were diagnosed by ultrasound and 2 patients (3%) also had PE at baseline. The most common veins involved were axillary (n=53, 76%) and subclavian (n=52, 74%), followed by the brachial, internal jugular, brachiocephalic and external jugular. Peripherally inserted central catheters (PICC) were the most common (n=56, 80%), followed by port-a-cath lines (n=14, 20%). Types of active malignancy included breast (n=22, 31%), colon (n=12, 17%), colorectal (n=7, 10%), lung (n=4, 6%), bladder (n=3, 4%), pancreatic (n=3, 4%) and other (n=19, 27%). Catheter survival was 57% at 12 weeks with no catheters removed due to thrombosis and all catheters were functional until removal or end of study. Reasons for CVC removal prior to the end of the study included end of therapeutic need (n=21), infection (n=3), accidentally fell out (n=3), patient preference (n=1), and death (n=2). One patient (1.4%) had a recurrent DVT in the same arm during the 3-month follow-up period. The 2 patient deaths were both due to underlying cancer. There were 7 bleeding events in 6 patients, 3 major (2.9%) and 4 CRNMB (5.7%). (1 patient had 2 major bleeds). Discussion In this study, Apixaban showed promise in treating CVC-associated UEDVT in cancer patients, resulting in high preserved CVC function.

S3593 Eosinophilic Gastritis in Idiopathic Hypereosinophilic Syndrome: A Case Report

Introduction: Idiopathic hypereosinophilic syndrome (IHES) is a group of myeloproliferative disorders causing multi-organ dysfunction with unknown etiology. We report a case of IHES in a patient presenting with gastric wall thickening, multiple organ damage including acute coronary syndrome, encephalopathy, and multiple cortical infarcts. Case Description/Methods: A 47-year-old male patient with past medical history significant for type 2 diabetes mellitus and hypertension presented with nausea, vomiting, abdominal pain, and food intolerance for 7 days. He also complained of intermittent, substernal chest pain for 1-2 days at presentation. His labs were significant for elevated troponin of serum creatinine of 2.85mg/dL and significant leukocytosis (32.80 10^3/cmm). Absolute eosinophilic count was elevated at 14.70 10^3/cmm. Echocardiogram showed hypokinetic mid inferior and inferolateral walls. CT chest/abdomen angiogram was done for concerns of dissection. It showed diffuse gastric wall thickening with upper abdominal retroperitoneal lymphadenopathy and extensive retroperitoneal fat stranding. He was started on antiplatelet agent and heparin drip. Ischemic workup was deferred as troponin plateaued and patient had new-onset altered mental status. MRI brain showed numerous punctate cortical and subcortical foci of restricted diffusion consistent with acute watershed distribution infarcts. In view of possible need for dual anti-platelet therapy and the high concern for gastric malignancy on CT that required tissue biopsy, gastroenterology was consulted for esophagogastroduodenoscopy (EGD). It did not show any gastric mass but diffuse gastritis. Biopsy showed mild chronic gastritis and a focal area showing increased eosinophilic infiltration with eosinophilic cryptitis (Figure). An extensive workup for eosinophilia including infectious etiology returned negative. No secondary causes of hypereosinophilia were identified. Patient was started on 1mg/kg of prednisone with normalization of eosinophils to 0 within 24 hours. Steroids were tapered and patient improved clinically with resolution of altered mental status, abdominal pain, and chest pain. Follow-up EGD has been scheduled to re-evaluate eosinophilic deposits. Discussion: The stomach biopsy showing eosinophilia was the key to diagnosis. Resolution of peripheral eosinophilia with steroids confirms the diagnosis in the absence of a secondary cause. A repeat EGD with biopsy is scheduled to look for histopathological resolution.Figure 1.: Gastric mucosa with increased eosinophilic infiltration within the lamina propria and focal glandular involvement with eosinophils.

Adherence to guidelines improves outcomes in coronary artery surgery

The present study in the current issue of the EJCTS addressed the highly relevant issue of prognostic impact of secondary prevention after coronary artery bypass grafting (CABG) [1, in this issue]. Unfortunately, disparities in the adherence to guideline recommended therapies after CABG still exist even though different guidelines have emerged as easily available tool to conduct the best evidence-based clinical practice. In the present analysis [1, in this issue], authors included all participants of the TiCAB study [2] aiming to evaluate the effect of guideline-adherent medical secondary prevention on 1-year outcome after CABG [1, in this issue]. TiCAB study enrolled coronary artery disease patients who were scheduled for CABG [2]. The primary outcome was the composite of cardiovascular death, myocardial infarction, repeat revascularization and stroke 12 months after CABG [2]. The main safety end-point was based on the Bleeding Academic Research Consortium classification [2, 3]. The need for dual antiplatelet therapy (DAPT) after surgery was considered as one of the major exclusion criteria [2]. About 25% of patients scheduled for CABG are expected to present with an Acute Coronary Syndrome (ACS) [2]. Thus, patients requiring DAPT after CABG were unfortunately not analysed in this study [1, in this issue]. It would be valuable to elucidate how would the inclusion of the aforementioned subgroup of patients influence the adherence to the guidelines [4]. Furthermore, it would be even more interesting how this adherence in the DAPT subgroup would reflect the clinical outcomes, be it the composite main outcome or the main safety end-point as defined in TiCAB [2].

Thrombosis or vasospasm: The utility of intraoperative neuromonitoring during TCAR.

Transcarotid artery revascularization (TCAR) has become more prevalent as a treatment modality for carotid stenosis. Many centers perform TCAR without any adjunctive neuromonitoring, for example, somatosensory-evoked potential (SSEP) and electroencephalogram (EEG). We present a case of transcarotid artery revascularization (TCAR) performed with concomitant somatosensory-evoked potential (SSEP) and electroencephalogram (EEG) neuromonitoring in the setting of concerning intraoperative angiographic images. TCAR was undertaken for a 58year-old man presenting with symptomatic left carotid stenosis and right ICA occlusion. Based on his comorbidities, pre-existing conditions, and the need for dual antiplatelet therapy, TCAR was offered as an alternative to standard carotid endarterectomy. Intraoperatively, following stent delivery, no flow was appreciated through the carotid stent or distal ICA. Neuromonitoring remained stable and was reassuring for distal ICA spasm with no-reflow phenomenon. The patient tolerated the procedure well and has had no stent-related complications through 10months of follow-up. This case highlights the utility of neuromonitoring with TCAR as an adjunct to intraoperative decision-making in the setting of suspected internal carotid artery (ICA) vasospasm versus thrombosis after stent delivery.

The current treatment and predictors of outcome in elderly patients with non-ST-elevation myocardial infarction in an all comers population: the POPular Age registry

Abstract Background Elderly patients form a large and growing part of the patients presenting with non-ST-elevation myocardial infarction (NSTEMI). Choosing the optimal antithrombotic treatment in these elderly patients is more complicated because they frequently have characteristics indicating both a high ischaemic and high bleeding risk. Purpose We describe the treatment of elderly patients (&amp;gt;75 years) admitted with NSTEMI, present the outcomes (major adverse cardiovascular events (MACE) and bleeding) and aim to find predictors for adverse events. Methods The POPular AGE registry is an investigator initiated, prospective, observational, multicentre study of patients aged 75 years or older presenting with NSTEMI. Patients were recruited between August 1st, 2016 and May 7th, 2018 at 21 sites in the Netherlands. The primary composite endpoint of MACE included cardiovascular death, non-fatal myocardial infarction and non-fatal stroke at one-year follow-up. Results A total of 757 patients were enrolled. During hospital stay 76% underwent coronary angiography, 34% percutaneous coronary intervention and 12% coronary artery bypass grafting (CABG). At discharge 78.6% received aspirin (non-users mostly because of the combination of oral anticoagulant and clopidogrel), 49.7% were treated with clopidogrel, 34.2% with ticagrelor and 29.6% were prescribed oral anticoagulation. Eighty-three percent of patients received dual antiplatelet therapy (DAPT) or dual therapy consisting of oral anticoagulation and at least one antiplatelet agent for a duration of 12 months. At one year, the primary outcome of cardiovascular death, myocardial infarction or stroke occurred in 12.3% of patients and major bleeding (BARC 3 or 5) occurred in 4.8% of the patients. The risk of MACE and major bleeding was highest during the first month and stayed high over time for MACE while the risk for major bleeding levelled off. Independent predictors for MACE were age, renal function, medical history of CABG, stroke and diabetes. The only independent predictor for major bleeding was haemoglobin level on admission. Conclusion In this all-comers registry, most elderly patients (≥75 years) with NSTEMI are treated with DAPT and undergoing coronary angiography the same way as younger NSTEMI patients from the SWEDEHEART registry. Aspirin use was lower as was the use of the more potent P2Y12 inhibitors compared to the SWEDEHEART which is very likely due to the concomitant use of oral anticoagulation in 30% of patients. The fact that ischemic risk stays constant over 1 year of follow-up, while the bleeding risk levels off after one month may suggest the need of dual antiplatelet therapy until at least one year after NSTEMI. Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): AstraZeneca

P2Y12 inhibition by clopidogrel increases adverse clinical outcomes in patients undergoing transcatheter aortic valve replacement

Abstract Introduction Current recommendations support short-term dual antiplatelet therapy (DAPT) for patients undergoing transcatheter aortic valve replacement (TAVR) despite no relevant study exploring the extent of platelet inhibition by clopidogrel. Purpose To assess whether P2Y12 inhibition by clopidogrel as evaluated by vasodilator-stimulated phosphoprotein flow cytometry test (VASP-FCT) impacts 1-year clinical outcomes in patients undergoing TAVR. Methods Patients were included in a prospective registry between February 2010 and May 2019. VASP-FCT was assessed 24h after the procedure. Responder to clopidogrel was defined by a platelet reactivity index ≤50%. Results Of 640 patients who underwent TAVR with preprocedural clopidogrel therapy, we enrolled 491 patients for whom VASP data were available. Responders were identified in 22% (n=110) of patients and low responders were 78% (n=381) of patients. Low body mass index, active cancer, and clopidogrel on admission were found to be independent predictors of responder. Mean transaortic pressure gradient was lower in the responder group at 1-month post-TAVR (9.9±4.4 mmHg vs. 11.2±5.8 mmHg, p=0.03) but was similar at 1-year (11.5±6.2 mmHg vs. 11.9±7.4 mmHg, p=0.74). By multivariate Cox regression analysis, patients responding to clopidogrel (hazard ratio [HR]: 2.19; 95% confidence interval [CI]: 1.04 to 3.64; p=0.04), prior PCI (HR: 2.12; 95% CI: 1.07 to 4.37; p=0.03), and mean transaortic pressure gradient at baseline (HR: 0.07; 95% CI: 0.01 to 0.70; p=0.02) were identified as independent predictors of 1-year adverse clinical outcomes, including all-cause death, myocardial infarction, stroke, and heart failure hospitalization. Conclusions Appropriate P2Y12 inhibition by clopidogrel is a major determinant of adverse clinical events after TAVR. In sum, the present data challenges the need of DAPT as a standard therapy during TAVR. Figure 1 Funding Acknowledgement Type of funding source: None

The High Bleeding Risk Patient with Coronary Artery Disease.

Out-of-hospital bleeding is a common complication after percutaneous coronary intervention (PCI) due to the concomitant need for dual antiplatelet therapy. A significant proportion of patients undergoing PCI carry specific clinical characteristics posing them at high bleeding risk (HBR), increasing the risk of hemorrhagic complications secondary to antithrombotic therapy. Identifying patients at HBR and adjust antithrombotic therapy accordingly to optimize treatment benefits and risk is a challenge of modern cardiology. Recently, multiple definitions and tools have been provided to help clinicians with prognostic stratification and treatment decision making in this subgroup.

Use of pCONUS HPC for the treatment of unruptured wide-necked bifurcation aneurysms: early clinical experience using single antiplatelet therapy

BackgroundIn recent years, a growing number of stents and stent-like devices have become available to facilitate the treatment of challenging aneurysms. However, the need for dual antiplatelet therapy can limit...

Snare salvage technique for deformed WEB device after deployment

The Woven EndoBridge (WEB) device is a new endovascular technology that allows safe and effective treatment of wide-neck bifurcation aneurysms without the need for dual antiplatelet therapy.1–4 The case is...

The p48 Flow Modulation Device with Hydrophilic Polymer Coating (HPC) for the Treatment of Acutely Ruptured Aneurysms: Early Clinical Experience Using Single Antiplatelet Therapy

BackgroundFlow diversion (FD) remains a potential treatment option following aneurysmal subarachnoid hemorrhage (aSAH) when standard options may not be feasible. However, it should not be considered a first-line treatment due to the need for dual antiplatelet therapy (DAPT). The hydrophilic polymer coating on the p48MW flow diverter (HPC, phenox) is a surface modification that inhibits platelet adhesion. This study aims to report on our early single-center experience using the p48MW HPC (phenox) flow diverter with single antiplatelet therapy (SAPT) following an aSAH.Materials and MethodsWe retrospectively identified all patients who had been treated with the p48MW HPC for aSAH under SAPT. All patients treated within 30 days following an aSAH were included. Any occurrence of thromboembolic and hemorrhagic complications was recorded alongside angiographic and clinical follow-up details.ResultsEight patients were identified. The mean interval between aSAH and FD was 6 days. Of the eight ruptured aneurysms, one was blister-like, one saccular, one mycotic, and the remaining five were dissecting aneurysms. Intraprocedural transient thrombus formation was observed in four patients (50%). Stent thrombosis was observed in one patient (12.5%) on day 3 with spontaneous recanalization after being switched onto DAPT. None of the aneurysms rebled after treatment. Two patients died due to cerebral vasospasm. Complete aneurysm occlusion had been achieved in all but one patient at angiographic follow-up (average 6 months).ConclusionsThis small series highlights the possibility and limitations of using the p48MW HPC with SAPT in ruptured aneurysms. Randomized trials with longer follow-up in larger cohorts are underway.