Prolonged Antiplatelet Therapy Research Articles

Drug-coated balloon versus drug-eluting stenting coronary angioplasty for ST-elevation myocardial infarction: a systematic review and meta-analysis of real-world studies

Abstract Funding Acknowledgements None. Introduction In the realm of ST-elevation myocardial infarction (STEMI), drug-eluting stent angioplasty (DES) is a well-established strategy for urgent revascularization. However, several challenges arise when selecting stents for these patients. These challenges include dealing with endothelial oedema and vasospasm during acute thrombotic occlusion. Moreover, there are concerns surrounding DES-related complications. These complications include the need for prolonged anti-platelet therapy, which increases the risk of bleeding, late stent thrombosis, and in-stent restenosis (ISR). In light of these issues, drug-coated balloons (DCB) have emerged as a compelling alternative. Purpose: This study aims to explore the safety and efficacy of DCB compared to conventional DES angioplasty in the management of STEMI. Methods A systematic literature search was conducted across electronic databases (PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov, reference lists of relevant publications, and grey literature sources) for studies published from the inception of DCB up to 31st August 2023. Results Nine eligible studies, consisting of four randomised controlled trials and two retrospective propensity-matched studies, were included. These studies, all single-center, involved a total of 2,122 patients (934 in the DCB versus 1,188 in the DES group) over a median follow-up period of 15 months (ranging from 6 to 36 months). The meta-analysis showed no statistically significant differences between DCB and DES angioplasty in terms of technical success (OR: 1.82, 95% CI: 0.22-15.08, p = 0.58), major adverse cardiovascular events (MACE) (OR: 1.24, 95% CI: 0.60–2.56, p = 0.57), all-cause mortality (OR: 1.20, 95% CI: 0.83–1.75, p = 0.33), cardiac death (OR: 1.40, 95% CI: 0.47-4.17, p = 0.54), cardiovascular-related hospitalization (OR: 0.72, 95% CI: 0.32-1.65, p = 0.44), recurrent myocardial infarction (OR: 0.99, 95% CI:0.34-2.90, p = 0.99), target lesion revascularization (OR: 1.15, 95% CI: 0.56–2.34, p = 0.71), late luminal loss (SMD: -0.25mm, 95% CI: -1.05 to 0.54, p = 0.53), postoperative TIMI flow (OR: 1.16, 95% CI: 0.54-2.50, p = 0.71), fractional flow reserve (MD: 0.012, 95% CI -0.018 to 0.032, p = 0.27), and bleeding risk (7.2% in DCB versus 7.5% in DES). It's noteworthy that 8.2% of patients in the DCB group required bailout stenting due to coronary artery dissection type C, a rate 10 times higher than that in the DES group (p < 0.005). Additionally, DCB angioplasty displayed a statistically significant presence of residual stenosis compared to DES angioplasty (OR: 6.48, 95% CI: 1.13-37.2, p = 0.04). Conclusion DCB angioplasty demonstrates promise but presents unique challenges in STEMI management, particularly in complex scenarios requiring bailout stenting and residual stenosis. The study contributes to the ongoing discussion about the role of DCBs in optimizing STEMI treatment, highlighting their potential benefits and areas of concern.

Hyperproduction of von Willebrand factor as an additional criteria for prolonging antiplatelet therapy after acute coronary syndrome

The purpose of the study was to assess the prospects for using the von Willebrand factor as an additional criterion for prolonging dual antiplatelet therapy in patients at risk of developing cardiovascular complications after acute coronary syndrome. The study involved 80 patients who underwent acute coronary syndrome and/or surgical treatment of coronary heart disease. In addition to the standard clinical study, the level of von Willebrand factor was determined in all patients. In a prospective follow-up after two years, the incidence of recurrent cardiovascular complications was assessed and the need for prolongation of dual antiplatelet therapy was retrospectively calculated using a risk assessment scale. Among patients with normal level of von Willebrand factor, no cardiovascular complications were recorded after two years of follow-up. A number of the most important factors were identified, including the von Willebrand factor, were used in the predictive model for the development of recurrent cardiovascular complications. The classification ability of the model showed 92.5 % agreement between the forecast results and the observation results. According to the risk score, longerterm dual antiplatelet therapy was required in 24 patients, only 6 of whom developed cardiovascular complications. Of the 13 patients with such complications, six patients needed to prolong therapy according to the risk assessment scale, and 4 patients required the standard duration of therapy. When using the prognostic model developed by us, the percentage of coincidence of the predicted unfavorable course of the disease with the actual development of a cardiovascular complication was higher: in 8 out of 13 cases. The developed prognostic model, including the determination of the von Willebrand factor level, makes it possible to predict with high reliability and certainty the likelihood of developing cardiovascular complications in patients with early coronary atherosclerosis and can be used to clarify the indications for prolonged dual antiplatelet therapy in addition to the risk assessment scale, in patients not undergoing percutaneous coronary intervention inclusive.

Clinical Outcomes of Prolonged Antiplatelet Therapy after Percutaneous Coronary Intervention in Chronic Kidney Disease Patients: A Systematic Review and Meta-Analysis

Background: The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) is not established in chronic kidney disease (CKD) patients. Objective: In this meta-analysis, we evaluated the efficacy and safety of long duration DAPT compared with short duration DAPT in CKD patients after PCI. Methods: We searched PubMed, Cochrane, and Embase to identify studies assessing the effect of DAPT duration in CKD patients with PCI. Endpoints included all-cause mortality, major adverse cardiovascular events (MACE), death or myocardial infarction (MI), revascularization, and bleeding. Event rates were compared with a random-effects model expressed by odds ratio (OR) and 95% confidence interval (CI). Results: Six studies were included. CKD patients with extended DAPT duration were at a lower risk of mortality (OR 1.40, 95% CI: 1.11–1.77), MACE (OR 1.33, 95% CI: 1.17–1.51), mortality or MI (OR 1.24, 95% CI: 1.10–1.40), and stroke (OR 1.28, 95% CI: 1.05–1.56). However, there was no significant difference in revascularization and bleeding events between the two groups. Mortality was higher in patients with dialysis or drug-eluting stent comparing short- to long-term DAPT. Conclusions: Prolonged DAPT might decrease the risk of mortality, MACE, and stroke in patients with CKD without any significant difference in bleeding or revascularization. Additional studies are required to determine whether long-term DAPT could be considered for most CKD patients after PCI.

Residual Right-to-Left-Shunt Following Transcatheter Patent Foramen Ovale Closure: The Role of Antithrombotic Treatment.

Transcatheter closure of patent foramen ovale (PFO) is a highly effective therapy for patients with left circulation thromboembolism, not attributable to other conditions. This retrospective cohort study investigates the impact of baseline foramen ovale anatomy on the severity of the postclosure shunt. Patients with PFO, who underwent percutaneous closure, were followed up for at least 5 years postimplantation. Patients were classified into two groups based on the presence of high-risk features of the baseline PFO anatomy. At the follow-up follow-up, residual right-to-left shunt was assessed for the high and non-highrisk anatomy groups, via transcranial Doppler at rest and after performing the Valsalva maneuver, with the injection of agitated saline. 38 patients were examined after a mean follow-up period of 9 ± 3 years after implantation. After retrospective evaluation of the baseline transthoracic and transesophageal echo studies, 14 patients with high-risk PFO anatomy were identified. The degree of the residual right-to-left shunt, as assessed by the number of microbubbles was higher in the high-risk PFO anatomy group compared to the non-high-risk group, both at rest [1.50 (IQR: 0.00-3.25) vs. 0.00 (IQR: 0.00-0.00), p < 0.001] and post-Valsalva maneuver [7.50 (IQR: 1.50- 10.25) vs. 0.00 (IQR: 0.00-3.75), p = 0.003]. Furthermore, in the high-risk group, more microbubbles were detected at rest (p = 0.008) and post-Valsalva (p = 0.002) in subjects without antiplatelet treatment compared to subjects on prolonged antiplatelet therapy. Baseline PFO anatomy affects the severity of the residual right-to-left shunt. Prolonged antiplatelet therapy may benefit patients with high-risk anatomical features.

Ticagrelor monotherapy after coronary stenting in patients requiring proton pump inhibitor and prolonged antiplatelet therapy.

Key Points Approximately half of patients undergoing coronary stenting are discharged on a proton‐pump inhibitor (PPI). Post‐hoc analysis of the large GLOBAL LEADERs trial finds PPI treatment and aspirin monotherapy after a year of dual antiplatelet therapy (DAPT) is associated with increased risk of ischemic events. In contrast, PPI treatment and continued ticagrelor monotherapy are not associated with increased ischemic events in the second year after stenting. This observational evidence suggests the GLOBAL LEADERS tested ticagrelor monotherapy regimen could be considered in patients requiring both prolonged antiplatelet therapy (&gt;12 months) and PPI for increased bleeding risk.

Persistent risk of vascular complications and efficacy of prolonged dual antiplatelet therapy after myocardial infarction

The article discusses data on the duration of risk retention and the main cause of vascular complications in patients with acute coronary syndrome. Preconditions for prolonged use of dual antiplatelet therapy after myocardial infarction are presented. The authors consider the results of a large, prospective, randomized, placebo-controlled, multinational PEGASUS-TIMI 54 study evaluating the efficacy and safety of the long-term use of acetylsalicylic acid combined with ticagrelor (P2Y12 platelet receptor blocker) in patients with a high risk of thrombotic complications of atherosclerosis in the period from 1 to 3 years after myocardial infarction. The article presents an analysis of optimal approaches to prolonged double antiplatelet therapy after myocardial infarction, taking into account the results of the PEGASUS-TIMI 54 study, which laid the foundation for current clinical guidelines. The PEGASUS-TIMI 54 study demonstrated the benefits of prolonged dual antiplatelet therapy for at least 4 years after myocardial infarction in patients with a high risk of atherothrombotic complications and confirmed the expediency to reduce the dose of ticagrelor from 90 to 60 mg twice daily for 1 year after the onset of the disease to ensure the best balance of efficacy and safety of treatment. The possibility of prolonging double antiplatelet therapy using a combination of ASA and ticagrelor at a dose of 60 mg twice daily for 1 year after myocardial infarction is provided for in the guidelines for medical use of ticagrelor and is enshrined in existing clinical guidelines. Presently, ticagrelor is the only P2Y12 platelet receptor inhibitor approved in the Russian Federation as an adjunct to ASA for the long-term prevention of atherothrombotic cardiovascular events.

Preoperative plasma D-dimer level may be predictive for success of cerebral reperfusion and outcome after emergency mechanical thrombectomy for intracranial large vessel occlusion

Presented retrospective analysis evaluated whether preoperative plasma D-dimer level may predict the success of cerebral reperfusion and outcome after emergency mechanical thrombectomy (MT) for intracranial large vessel occlusion (ILVO). Study cohort comprised 121 patients (mean age, 76 ± 12 years) from two participating centers. ILVO mostly affected the M1 segment (48 cases) and internal carotid artery (ICA; 37 cases). Mean preoperative National Institutes of Health Stroke Scale (NIHSS) score was 18 ± 8. Mean preoperative plasma D-dimer level was 4.4 ± 6.6 μg/ml. In 88 patients (73%) MT resulted in successful cerebral reperfusion. Multivariate analysis revealed independent associations of non-successful cerebral reperfusion with preoperative plasma D-dimer level > 6.7 μg/ml (P = 0.0021), location of ILVO other than ICA (P = 0.0056), and prolonged antiplatelet or anticoagulant therapy before stroke onset (P = 0.0172). Plasma D-dimer level ≤ 6.7 μg/ml predicted successful cerebral reperfusion with 0.91 sensitivity and 0.36 specificity. In 39 patients (32%) treatment resulted in favorable outcome. Multivariate analysis revealed independent associations of the unfavorable outcome with non-successful cerebral reperfusion after MT (P = 0.0005), preoperative plasma D-dimer level > 1.9 μg/ml (P = 0.0131), higher preoperative NIHSS score (P = 0.0171), and chronic arterial hypertension before stroke onset (P = 0.0254). Plasma D-dimer level ≤ 1.9 μg/ml predicted favorable outcome with 0.64 sensitivity and 0.62 specificity. In conclusion, preoperative plasma D-dimer level may be predictive for success of cerebral reperfusion and outcome after emergency MT for ILVO, which may be potentially helpful for prediction of prognosis in selected treatment candidates.

Long-term follow up after percutaneous PFO closure. Does baseline PFO anatomy affect the long term procedural result and the severity of residual shunt?

Abstract Background Patent foramen ovale (PFO) has been increasingly identified as a cause for left circulation thromboembolism. The risk is even higher in patients with specific anatomic features, like atrial septal aneurysm (ASA), prominent Eustachian valve and Chiari network. Transcranial Doppler with detection of high intensity signals (HITS), after injection of agitated saline, contributes to diagnosis and follow up of patients with PFO. Percutaneous PFO closure is a well-established therapy, if indicated. It remains though unclear, whether the baseline anatomy has an impact on the long-term procedural result. Purpose To investigate if there was a difference in the number of detected HITS after bubble test in patients with baseline high-risk anatomy in comparison to patients without complex features at least 1 year post-procedurally. Methods Consecutive patients, who underwent percutaneous closure, were investigated at least one year post implantation. Patients were classified in two groups according to presence or not of high-risk baseline anatomy. Every patient underwent transcranial Doppler with bubble test with agitated saline at rest and after Valsalva maneuver with documentation of HITS up to 60 sec after the straining maneuver. Results 38 consecutive patients were included (42% men) with mean age 51±12 years and a mean follow-up period of 9±3 years. At baseline 14 patients (37%) had high risk anatomy (7 patients with ASA, 3 with Chiari network and 4 with prominent eustachian valve). There was no difference between the two groups in the mean age (no high-risk: 53±11 years vs high-risk: 48±13 years, p=0.22), in the duration of follow-up period (no high-risk: 9±3 years vs high-risk: 10±2 years, p=0.66) and in other risk factors (Table). The number of documented HITS after Valsalva maneuver was significantly higher in patients with high-risk morphological features [7.50 (10.25–1.50) vs. 0.00 (0.00–3.75), p=0.003] (Figure, panel A). [bo2] Among patients with high risk features six were on prolonged antiplatelet therapy with either aspirin or P2Y12-inhibitor. Patients with high-risk features on prolonged therapy had significant lower HITS [1.00 (0.00–3.25)] compared to patients with high risk features and no prolonged antiplatelet therapy [10.00 (8.25–13.25)] (p=0.008) (Figure, panel B). Recurrent cerebrovascular accidents were similar in both groups (2 events with high-risk anatomy and 1 event without). No patient regardless of PFO morphology and antiplatelet strategy showed a significant right to left shunt (&amp;gt;30 HITS according to Spencer scale) Conclusion Percutaneous PFO closure is an effective therapy for paradoxical left circulation thromboembolism. Patients with high-risk anatomy may show an increased prevalence of residual, though clinically irrelevant shunt and may require a stricter follow-up. Prolonged antiplatelet therapy may reduce the number of detected microbubbles. Randomized data are required to evaluate this hypothesis. Funding Acknowledgement Type of funding sources: None. HITS-anatomy-antiplatelet therapy

Epitaph for bare‐metal stents: Unlearning is hard to do

Key Points Use of bare metal stents (BMS) saw a significant decline between 2013 and 2017 across 18 medical centers in Italy. Indications for BMS most frequently included perceived risk of thrombosis during STEMI therapy or bleeding in the elderly or others from prolonged antiplatelet therapy despite information that was available to the contrary. Persistent use of BMS represents an example of the problem of unlearning old information so that new and better practice patterns can be incorporated into practice.

Association of lipoprotein(a) with platelet aggregation and thrombogenicity in patients undergoing percutaneous coronary intervention

This study aimed to evaluate the association of lipoprotein(a) levels with platelet aggregation and thrombogenicity in patients undergoing percutaneous coronary intervention (PCI), and to investigate the ischemic outcome on this population. Lipoprotein(a) and modified thrombelastography were measured in 6601 consecutive patients underwent PCI on dual antiplatelet therapy. Cox proportional regression analysis was applied to illustrate the ischemic events in a 2-year follow up. The mean levels of lipoprotein(a) were 29.0 mg/dl. Patients with higher lipoprotein(a) levels had significantly accelerated fibrin generation (lower K time and bigger α angle) and greater clot strength (higher maximum amplitude (MA)) than patients with lower lipoprotein(a) levels (P < .001). Moreover, the higher lipoprotein(a) group also exhibited significantly higher adenosine diphosphate (ADP) induced platelet aggregation (MAADP) by thrombelastography platelet mapping assay than lower lipoprotein(a) group. Cox regression analyzes revealed that patients with higher lipoprotein(a) levels had a 16% higher risk of major adverse cardiovascular and cerebrovascular events (HR 1.159, 95%CI: 1.005–1.337, P = .042) compared with patients with lower lipoprotein(a) levels. This association persisted after adjustment for a broad spectrum of risk factors (HR 1.174, 95%CI: 1.017–1.355, P = .028). High plasma lipoprotein(a) levels were associated with increased platelet aggregation and ischemic events in patients underwent PCI. Lipoprotein(a) might indicate the need for prolonged antiplatelet therapy.

The role of clopidogrel in the current treatment of acute coronary syndrome

In the article, a review is given of the facts that determined contemporary views of the role of clopidogrel in the treatment of acute coronary syndrome. The author described a history of the clinical studies of clopidogrel in acute coronary syndrome (ACS), analysed its role in the current approaches to the treatment of the disease during the widespread use of other platelet P2Y 12 receptor antagonists (ticagrelor and prasugrel). The article discusses circumstances, when clopidogrel may have additional advantages, particularly the role of adherence to prolonged double antiplatelet therapy, as well as situations, when sever suppression of platelet function can be decreased (treatment de-escalation). According to a prospective randomized open-label PoPular Age study, clopidogrel combined with acetylsalicylic acid in patients with ACS without persistent ST segment elevations at the age of ≥70 years showed better adherence to treatment over the coming year as compared with clopidogrel combined with ticagrelor or prasugrel. As a result, these two approaches had comparable efficacy. Today, treatment de-escalation is a necessary measure to extend the double antiplatelet therapy in cases, when continued administration of prasugrel or ticagrelor appears unacceptable. There is insufficient evidence for the routine implementation of de-escalation in stented patients with ACS, although a small prospective, one-centre randomized open-label ToPIC study shows that this approach is safe. The author provides a review of the results of recently presented prospective studies on the choice of a platelet P2Y 12 receptor antagonist for long-term treatment of acute coronary syndrome, taking into account the residual platelet reactivity and cytochrome p450 2c19 genetic polymorphisms. Among them are multicenter open randomized clinical TRoPICAL-ACS study, multicenter randomized open-label PoPular Genetics and TAILoR PCI studies. According to the study results, the long-term outcomes in stented patients with ACS with a good response to clopidogrel assessed by the residual functional activity of platelets or by studying cytochrome p450 2c19 genetic polymorphisms may not be worse than those during use of prasugrel or ticagrelor.

Guanxinning tablet for patients who switch from dual antiplatelet therapy to aspirin alone after percutaneous coronary intervention: study protocol for\xa0a cluster randomized controlled trial

BackgroundOne-year dual antiplatelet therapy (DAPT), generally aspirin in combination with a P2Y12 receptor inhibitor, has been a standard treatment for patients undergoing percutaneous coronary intervention (PCI). Prolonged DAPT has proven itself effective in further reducing cardiovascular events, yet with increased risk of bleeding. Thus, it is of great necessity to find an alternative drug that is as effective but safer and more economic than the P2Y12 inhibitors after termination of one-year DAPT.MethodsWe will conduct a cluster randomized controlled trial in 3600 eligible post-PCI patients from 36 tertiary hospitals (100 patients per hospital) across mainland China. The hospitals served as clusters are randomized in a 2:1 ratio to Guanxinning tablet (GXNT) plus aspirin or aspirin alone for 12 months, with other conventional treatment applied in both groups. After the treatment period, all patients will be followed up for another 12 months. The primary outcome measure is composite cardiovascular events including cardiovascular death, non-fatal myocardial infarction, stent thrombosis, revascularization, ischemic stroke, and re-admission due to unstable angina. Secondary outcome measures are all-cause mortality, each individual component of the primary outcome measure, and stopping or reducing the rate of nitroglycerin administration. Adverse events, including bleeding, will be closely monitored during the whole trial period. In addition, a cost-effectiveness study of GXNT for the study population will be conducted along with this trial.DiscussionThis trial aims to determine whether the addition of GXNT will further improve prognosis without increasing bleeding risk for patients with coronary artery disease who have switched from DAPT to aspirin alone after PCI. Completion of this clinical trial might provide a novel, promising, and safer alternative to P2Y12 inhibitors for prolonged antiplatelet therapy in post-PCI patients.Trial registrationChinese Clinical Trial Registry, ChiCTR-IIR-17010688. Registered on 20 February 2017.

Treatment of Intracranial Aneurysms With the SILK Embolization Device in a Multicenter Study. A Retrospective Data Analysis.

BACKGROUNDFlow-diverter technology has become an important stent-based embolization tool in the treatment of complex cerebrovascular pathology. We report here the experience of 4 Spanish centers with using the SILK flow-diverter (SFD) device.OBJECTIVETo evaluate the safety and efficacy of using the SFD in the endovascular treatment of intracranial aneurysms with complex morphology.METHODSWe retrospectively examined a prospectively maintained database of patients treated with SFD devices between July 2008 and December 2013 at 1 of 4 institutions in Spain. Data regarding patient demographics, aneurysm characteristics, and technical procedure were analyzed. Angiographic and clinical findings were recorded during the procedure and at 12 months postoperatively.RESULTSA total of 175 SFD devices were implanted in 157 patients (women/men: 119/38; mean, median, and range of age: 56.2, 56.7, and 19-80 years, respectively), who were treated in a delayed manner (3-6 months from the event) for 180 aneurysms (165 unruptured and 15 ruptured). Adverse events (acute and delayed) were observed in 28.7% of cases (45/157), and most were resolved (19.1%; 30/157). Six months after the procedure, total morbidity and mortality were 9.6% (15/157) and 3.2% (5/157), respectively. Long-term imaging follow-up showed complete occlusion, neck remnants, and residual aneurysm in 78.1% (100/128), 14.0% (18/128), and 7.8% (10/128) of cases, respectively.CONCLUSIONSThe SFD device is an effective tool for the treatment of challenging aneurysms, and allows complete occlusion within a year of the procedure in most patients, with morbidity and mortality comparable to those previously reported for similar devices.

Combining clinical and angiographic variables for estimating risk of target lesion revascularization after drug eluting stent placement

Drug-eluting stents (DES) reduce restenosis but require prolonged antiplatelet therapy, when compared with bare metal stents. Ideally, the patient should be involved in this risk:benefit assessment prior to selecting DES, to maximize the benefits and cost-effectiveness of care, and to improve medication adherence. However, accurate estimation of restenosis risk may require angiographic factors identified at cardiac catheterization. In a large PCI registry, we used logistic regression to identify clinical and angiographic predictors of clinically-driven target lesion revascularization (TLR) over the first year after stent placement. Discrimination c-statistic and integrated discrimination improvement (IDI) were used to calculate the incremental utility of angiographic variables when added to clinical predictors. Of 8501 PCI patients, TLR occurred in 4.5%. After adjusting for DES use, clinical TLR predictors were younger age, female sex, diabetes, prior PCI, and prior bypass surgery (model c-statistic 0.630). Angiographic predictors were vein graft PCI, in-stent restenosis lesion, longer stent length, and smaller stent diameter (c-statistic 0.650). After adding angiographic factors to the clinical model, c-statistic improved to 0.680 and the average separation in TLR risk among patients with and without TLR improved by 1% (IDI=0.010, 95% CI 0.009-0.014), primarily driven by those experiencing TLR (from 5.9% to 6.9% absolute risk). Among unselected PCI patients, the incidence of clinically-indicated TLR is <5% at 1-year, and standard clinical variables only moderately discriminate who will and will not experience TLR. Angiographic variables significantly improve TLR risk assessment, suggesting that stent selection may be best performed after coronary anatomy has been delineated. Although several recent studies have challenged traditional expectations regarding the duration of dual antiplatelet therapy, current guidelines recommend at least 6 to 12months of treatment after implantation of a drug eluting stent, with a shorter course for bare metal stents. Stent selection ideally should involve input from the patient receiving these stents, but multiple studies have suggested that angiographic factors - obtained after the patient has received sedation during the diagnostic catheterization - are important predictors of repeat revascularization. In this analysis from a large registry of patients receiving coronary stents, angiographic characteristics were found to significantly improve risk assessment for target lesion revascularization, when added to clinical variables alone.

Contribution of whole platelet aggregometry to the endovascular management of unruptured aneurysms: an institutional experience

BackgroundStent-assisted coiling of intracranial aneurysms is an efficient alternative treatment to surgical clipping but requires prolonged antiplatelet therapy. Some patients are non-responsive to aspirin and/or clopidogrel.ObjectiveTo analyze the implications of...

304 The Contribution of Whole Platelet Aggregometry to the Endovascular Management of Unruptured Aneurysms

Abstract Stent-assisted coiling of intracranial aneurysms is a viable and efficient treatment alternative to surgical clipping but requires prolonged antiplatelet therapy. Some patients can be nonresponsive to aspirin and/or clopidogrel. This is the first study analyzing the implications of this assessment using the whole blood aggregometry (WBA) by impedance technique. The Southwestern Tertiary Aneurysm Registry (STAR) was reviewed between 2002 and 2012 for patients with unruptured aneurysms treated with stent-assisted coiling. The study population was divided into patients who were tested preoperatively for platelet responsiveness to aspirin and clopidogrel (tested patients) and those who were not (nontested patients). Where necessary, a majority of tested patients received additional doses of antiplatelet drugs to achieve adequate platelet inhibition. End points included the incidence of antiaggregant nonresponsiveness, the rates of thrombotic and hemorrhagic complications, and the rates of permanent morbidity and mortality. A total of 266 patients fulfilled our selection criteria. There were 114 nontested patients who underwent 121 procedures, and 152 tested patients who underwent 171 procedures. The 2 groups did not vary significantly in patient age, sex, and aneurysms location. Aspirin nonresponsiveness was detected in 3 patients (1.75%) and clopidogrel nonresponsiveness was detected in 21 patients (12.3%). Nontested patients had an 11.5% rate of thrombotic complications with a 4.23% permanent morbidity or mortality rate vs 2.3% and 0.58% in tested patients (P = .001). The incidence of hemorrhagic complications was similar between the 2 groups. Preoperative platelet inhibition testing using WBA can be useful to assess and correct antiaggregant nonresponsiveness, and may reduce postoperative mortality and permanent morbidity.

A review on biodegradable materials for cardiovascular stent application

A stent is a medical device designed to serve as a temporary or permanent internal scaffold to maintain or increase the lumen of a body conduit. The researchers and engineers diverted to investigate biodegradable materials due to the limitation of metallic materials in stent application such as stent restenosis which requires prolonged anti platelet therapy, often result in smaller lumen after implantation and obstruct re-stenting treatments. Biomedical implants with temporary function for the vascular intervention are extensively studied in recent years. The rationale for biodegradable stent is to provide the support for the vessel in predicted period of time and then degrading into biocompatible constituent. The degradation of stent makes the re-stenting possible after several months and also ameliorates the vessel wall quality. The present article focuses on the biodegradable materials for the cardiovascular stent. The objective of this review is to describe the possible biodegradable materials for stent and their properties such as design criteria, degradation behavior, drawbacks and advantages with their recent clinical and preclinical trials.

Prolonged antiplatelet therapy after drug-eluting stents

Prolonged antiplatelet therapy after drug-eluting stents

Ischemic Brain Lesions After Carotid Artery Stenting Increase Future Cerebrovascular Risk

BackgroundBrain lesions on diffusion-weighted imaging (DWI) are frequently found after carotid artery stenting (CAS), but their clinical relevance remains unclear. ObjectivesThis study sought to investigate whether periprocedural ischemic DWI lesions after CAS or carotid endarterectomy (CEA) are associated with an increased risk of recurrent cerebrovascular events. MethodsIn the magnetic resonance imaging (MRI) substudy of ICSS (International Carotid Stenting Study), 231 patients with symptomatic carotid stenosis were randomized to undergo CAS (n = 124) or CEA (n = 107). MRIs were performed 1 to 7 days before and 1 to 3 days after treatment. The primary outcome event was stroke or transient ischemic attack in any territory occurring between the post-treatment MRI and the end of follow-up. Time to occurrence of the primary outcome event was compared between patients with (DWI+) and without (DWI–) new DWI lesions on the post-treatment scan in the CAS and CEA groups separately. ResultsMedian time of follow-up was 4.1 years (interquartile range: 3.0 to 5.2). In the CAS group, recurrent stroke or transient ischemic attack occurred more often among DWI+ patients (12 of 62) than among DWI– patients (6 of 62), with a cumulative 5-year incidence of 22.8% (standard error [SE]: 7.1%) and 8.8% (SE: 3.8%), respectively (unadjusted hazard ratio: 2.85; 95% confidence interval: 1.05 to 7.72; p = 0.04). In DWI+ and DWI– patients, 8 and 2 events, respectively, occurred within 6 months after treatment. In the CEA group, there was no difference in recurrent cerebrovascular events between DWI+ and DWI– patients. ConclusionsIschemic brain lesions discovered on DWI after CAS seem to be a marker of increased risk for recurrent cerebrovascular events. Patients with periprocedural DWI lesions might benefit from more aggressive and prolonged antiplatelet therapy after CAS. (A Randomised Comparison of the Risks, Benefits and Cost Effectiveness of Primary Carotid Stenting With Carotid Endarterectomy: International Carotid Stenting Study; ISRCTN25337470)

Select Articles Published on the Topic of Coronary Heart Disease in 2013

Select Articles Published on the Topic of Coronary Heart Disease in 2013