Withdrawal Of Antiplatelet Therapy Research Articles

Bleeding complications, coagulation disorders, and their management in acute myocardial infarction-related cardiogenic shock rescued by veno-arterial ECMO: A retrospective cohort study

PurposeManagement of dual antiplatelet therapy (DAPT) in patients on venoarterial-extracorporeal membrane (VA-ECMO) after acute myocardial infarction (AMI) is challenging. Our objective was to describe the frequency, management and outcomes of severe bleeding complications and determine their occurrence risk factors. Material and methodsWe conducted a retrospective observational cohort study including post-AMI cardiogenic shock patients requiring VA-ECMO. Severe bleeding was defined based on the Bleeding Academic Research Consortium classification. We calculated multivariable Fine–Gray models to assess factors associated with risk of severe bleeding. ResultsFrom January 2015 to July 2019, 176 patients received VA-ECMO after AMI and 132 patients were included. Sixty-five (49%) patients died. Severe bleeding occurred in 39% of cases. Severe thrombocytopenia (< 50 G/L) and hypofibrinogenemia (<1,5 g/L) occurred in respectively 31% and 19% of patients. DAPT was stopped in 32% of patients with a 6% rate of stent thrombosis. Anticoagulation was stopped in 39% of patients. Using a multivariate competing risk model, female sex, time on ECMO, troponin at admission and Impella® implantation were independently associated with severe bleeding. ConclusionsBleeding complications and coagulation disorders were frequent and severe in patients on VA-ECMO after AMI, leading of antiplatelet therapy withdrawal in one third of patients.

Endoscopic Papillary Balloon Dilation Can Be Safely Performed in Patients on Dual Antiplatelet Therapy: A Pilot Study.

Endoscopic papillary balloon dilation (EPBD), a low-risk procedure for bleeding, has been suggested as an alternative to endoscopic sphincterotomy for papillary dilatation in patients undergoing endoscopic stone removal who are at a higher risk of bleeding. Several guidelines recommend that combination of two antiplatelet agents should be reduced to single antiplatelet therapy when endoscopic sphincterotomy is performed. However, there is no evidence that EPBD affects the risk of bleeding in patients receiving a combination of two antiplatelet agents; thus, we aimed to explore this problem. We included 31 patients who underwent EPBD for common bile duct stones at our hospital from May 2014 to August 2022 and received either a combination of two antiplatelet agents or single antiplatelet therapy prior to the procedure. The group receiving a combination of two antiplatelet agents included patients who underwent EPBT without antiplatelet therapy withdrawal or with a shorter withdrawal period than those recommended by the guidelines. In the group that received a combination of two antiplatelet agents, one of the two antiplatelet agents used was thienopyridine. No bleeding was observed after EPBD in this study. We did not find any significant between-group differences in hemoglobin levels and rate of post-endoscopic retrograde cholangiopancreatography pancreatitis. In patients treated with a combination of two antiplatelet agents, EPBD could be safely performed without bleeding. Therefore, future prospective studies are warranted.

A patient with pulseless ST elevation myocardial infarction caused by a very late stent thrombosis

Background: Persistent contrast staining is highly associated with stent thrombosis. Case summary: A 75-year-old woman presented with new-onset effort angina. A coronary angiogram revealed a 90% blockage of the distal left main trunk (LMT) and a 99% blockage of the ostial left anterior descending coronary artery (LAD). A 3.0 × 18-mm CYPHER™ the stent had previously been implanted into the dominant proximal circumflex artery (LCx) in 2009 because of unstable angina. The patient developed pulseless ST elevation myocardial infarction after the withdrawal of antiplatelet therapy before a scheduled CABG. The patient recovered with VA-ECMO and PCI using aspiration thrombectomy and urgent CABG. Discussion: This case highlighted that a preoperative patient may develop thrombosis at a previous stent site with peri-stent contrast staining and withdrawal of an antiplatelet regimen in certain settings poses an imminent risk for preoperative deterioration. A bridging strategy using intravenous PY12 inhibitor before CABG should be considered in this setting. The revascularization strategy should be selected based on coronary anatomy, hemodynamic status and baseline risk for CABG. A hybrid revascularization approach should be considered in this patient population.

Balloon Angioplasty Combined with Tirofiban as a First-Line Rescue Treatment After Failed Mechanical Thrombectomy for Middle Cerebral Artery Occlusion with Underlying Atherosclerosis

The standard rescue modality for patients with intracranial atherosclerotic stenosis after failed mechanical thrombectomy (MT) is not well established. We evaluated the safety and efficacy of balloon dilation in combination with tirofiban as the first-line salvage therapy when MT failed in these patients. We retrospectively analyzed the records of 47 patients admitted between January 2018 and June 2021, with middle cerebral artery atherosclerotic occlusion, who underwent balloon angioplasty in combination with tirofiban as the first-line salvage therapy after the failure of MT. The recanalization outcome, procedure-related complications, symptomatic intracranial hemorrhage, and functional outcome at 90days were reviewed. Recanalization with a modified Thrombolysis in Cerebral Infarction grade of 2b-3 was achieved in 41 (87.2%) of the 47 patients. Acute stents were deployed in another 6 patients who did not achieve successful re-perfusion after balloon angioplasty. Successful recanalization was achieved in 3 of them. One patient (2.1%, 1/47) experienced re-occlusion several days later due to the withdrawal of antiplatelet therapy for parenchymal hematoma. Seven patients (14.9%, 7/47) underwent stent angioplasty in the stable stage (range: 1-2months) because severe residual stenosis was detected on follow-up imaging. There was only one event of periprocedural complication, namely ectopic migration of emboli. The good functional outcome rate was 55.3% (26/47), without the events of symptomatic intracranial hemorrhage and mortality. Balloon angioplasty in combination with tirofiban is safe and effective for middle cerebral artery atherosclerotic occlusion after the failure of MT.

Clinical approach of botulinum toxin A (Botoxⓡ) of treatment for patients with overactive bladder

Candidates for botulinum toxin A are generally patients with overactive bladder(OAB) whose disease is in adequatelycontrolled with behavioral therapy and oral medication. All patients must be willing and able to perform cleanintermittent catheterization(CIC). Before the decision to administer botulinum toxin A is made, the clinician shouldprovide counseling to the patient regarding the agent’s indications, proposed benefis, risks, and mode ofadministration. The patient should be aware that botulinum toxin A takes effect after approximately 1?2weeks andusually lasts for 4?10months, after which repeat injections will be necessary to maintain effect. Patient preparation mayinclude pre-treatment antibiotics and withdrawal of antiplatelet therapy or anticoagulants. Preparation of the productinvolves reconstitution in sterile saline and dilution according to the planned dose. The injections are performed using aflxible or rigid cystoscope, and the procedure takes approximately 15 min. The initial follow-up visit occurs within 7?14days, when evidence of adverse effects, including urinary retention, can be evaluated. Repeat injections can bescheduled as needed, but not sooner than 3 months. Currently, the total dose of botulinum toxin A should not exceed360 U in a 3-month period for all indications, including those outside the urinary tract (i.e.,cosmetic,ophthalmologic,etc.). Overall, botulinum toxin A is effective, generally well tolerated, safe, and is relatively simple toprovide.

Coronary stenting and surgery: perioperative management of antiplatelet therapy in patients undergoing surgery after coronary stent implantation

The management of antiplatelet therapy in patients with coronary stents undergoing surgery is a growing clinical problem and often represents a matter of debate between cardiologists and surgeons. It has been estimated that about 4-8% of patients undergoing coronary stenting need to undergo surgery within the next year. Surgery represents one of the most common reasons for premature antiplatelet therapy discontinuation, which is associated with a significant increase in mortality and major adverse cardiac events, in particular stent thrombosis. In addition, surgery confers an additional risk of perioperative cardiac ischemic events, being high in these patients because of the pro-inflammatory and pro-thrombotic effects of surgery. Current international guidelines recommend to postpone non-urgent surgery for at least 6 weeks after bare metal stent implantation and for 6-12 months after drug-eluting stent implantation. However, these recommendations provide little support with regard to managing antiplatelet therapy in the perioperative phase in case of urgent operations and/or high hemorrhagic risk. Furthermore, ischemic and hemorrhagic risk is not defined in detail on the basis of clinical and procedural characteristics. Finally, guidelines shared with cardiologists and surgeons are lacking. The present consensus document provides practical recommendations on the management of antiplatelet therapy in the perioperative period in patients with coronary stents undergoing surgery. Cardiologists and surgeons contributed equally to its creation. An ischemic risk stratification has been provided on the basis of clinical and procedural data. All surgical interventions have been defined on the basis of the hemorrhagic risk. A consensus on the most appropriate antiplatelet regimen in the perioperative phase has been reached on the basis of the ischemic and hemorrhagic risk. Dual antiplatelet therapy should not be withdrawn for surgery at low bleeding risk, whereas aspirin should be continued perioperatively in the majority of surgical operations. In the event of interventions at high risk for both bleeding and ischemic events, when oral antiplatelet therapy withdrawal is required, perioperative treatment with short-acting intravenous glycoprotein IIb/IIIa inhibitors (tirofiban or eptifibatide) should be considered.

Abstract 18519: Withdrawal of Antiplatelet Therapy Results in Worse Short-term Prognosis in Patients Undergoing Elective Major Noncardiac Surgery

Background: The decision whether to discontinue antiplatelet therapy in patients undergoing major noncardiac surgery can be clinically challenging. There is insufficient clinical evidence to establish comprehensive guidelines and most of recommendations are based on expert consensus. Objective: To evaluate the effectof withdrawal of antiplatelet therapy on 30-day postoperative outcome in subjects undergoing elective major noncardiac surgery. Methods: A retrospective cohort study was performed in 1630 patients, 40 years and older, who underwent major noncardiac surgery. Age, gender, risk factors, previous chronic heart or lung disease, renal function, anemia and concomitant treatment were used in a binary logistic regression to determine the impact of withdrawal of antiplatelet therapy on prognosis. The primary outcome measure was a composite of 30-day postoperative mortality or cardiovascular events (cardiac arrest, myocardial infarction, stroke or pulmonary embolism). Results: Five percent of patients presented the composite primary outcome measure of 30-day postoperative mortality or cardiovascular events. Antiplatelet therapy was withdrawn in 11.4% of patients (table). Discontinuation of antiplatelet therapy was associated with a significant increase in the primary outcome measure (OR 2.27; CI95%: 1.16-4.46). Conclusions: In a contemporary cohort of patients undergoing noncardiac surgery, withdrawal of antiplatelet therapy was associated with a worse short-term prognosis. There is an urgent need for further research in this field.

Chapter 6: Practical aspects of administration of onabotulinumtoxinA.

Candidates for onabotulinumtoxinA are generally patients with overactive bladder (OAB) or neurogenic detrusor overactivity (NDO) whose disease is inadequately controlled with behavioral therapy and oral medication. All patients must be willing and able to perform clean intermittent catheterization (CIC). Before the decision to administer onabotulinumtoxinA is made, the clinician should provide counseling to the patient regarding the agent's indications, proposed benefits, risks, and mode of administration. The patient should be aware that onabotulinumtoxinA takes effect after approximately 1-2 weeks and usually lasts for 4-10 months, after which repeat injections will be necessary to maintain effect. Patient preparation may include pre-treatment antibiotics and withdrawal of antiplatelet therapy or anticoagulants. Preparation of the product involves reconstitution in sterile saline and dilution according to the planned dose. Local anesthesia (e.g., bladder instillation of lidocaine) is usually administered, although general anesthesia may be used in certain cases. The injections are performed using a flexible or rigid cystoscope, and the procedure takes approximately 15 min. The initial follow-up visit occurs within 7-14 days, when evidence of adverse effects, including urinary retention, can be evaluated. Repeat injections can be scheduled as needed, but not sooner than 3 months. Currently, the total dose of onabotulinumtoxinA should not exceed 360 U in a 3-month period for all indications, including those outside the urinary tract (i.e., cosmetic, ophthalmologic, etc.). Overall, onabotulinumtoxinA is effective, generally well tolerated, safe, and is relatively simple to provide.

Oral antiplatelet therapy after drug-eluting stent implantation

Prolonged dual antiplatelet therapy is the cornerstone of the therapy after drug-eluting stent implantation. However, it is associated with risks and side-effects, such as bleeding events, which can negatively affect overall prognosis. Moreover, premature antiplatelet therapy discontinuation is not uncommon both in clinical trials and in clinical practice. It can lead to serious short-term and long-term complications, such as stent thrombosis, acute myocardial infarction and death. Although lack of patient's motivation can be regarded as an important cause of drug withdrawal, recent studies showed that medical decisions can be an even more frequent cause of premature discontinuation. The management of a patient with a coronary stent, undergoing surgery, is challenging and might lead to antiplatelet therapy withdrawal. In the present article, adherence and side-effects of antiplatelet therapy will be reviewed, also focusing on new antiplatelet drugs, such as prasugrel and ticagrelor. Furthermore, pharmacological interactions (e.g. proton pump inhibitors) as well as other causes of drug discontinuation will be addressed, particularly focusing on their prognostic and practical implications.

Clinical review: Traumatic brain injury in patients receiving antiplatelet medication

As the population ages, emergency physicians are confronted with a growing number of trauma patients receiving antithrombotic and antiplatelet medication prior to injury. In cases of traumatic brain injury, pre-injury treatment with anticoagulants has been associated with an increased risk of posttraumatic intracranial haemorrhage. Since high age itself is a well-recognised risk factor in traumatic brain injury, this population is at special risk for increased morbidity and mortality. The effects of antiplatelet medication on coagulation pathways in posttraumatic intracranial haemorrhage are not well understood, but available data suggest that the use of these agents increases the risk of an unfavourable outcome, especially in cases of severe traumatic brain injury. Standard laboratory investigations are insufficient to evaluate platelet activity, but new assays for monitoring platelet activity have been developed. Commonly used interventions to restore platelet activity include platelet transfusion and application of haemostatic drugs. Nevertheless, controlled clinical trials have not been carried out and, therefore, clinical practice guidelines are not available. In addition to the risks of the acute trauma, patients are at risk for cardiac events such as life-threatening stent thrombosis if antiplatelet therapy is withdrawn. In this review article, we summarize the pathophysiologic mechanisms of the most commonly used antiplatelet agents and analyse results of studies on the effects of this treatment on patients with traumatic brain injury. Additionally, we focus on opportunities to counteract antiplatelet effects in those patients as well as on considerations regarding the withdrawal of antiplatelet therapy. In those chronically ill patients, an interdisciplinary approach involving intensivists, neurosurgeons as well as cardiologists is often mandatory.

Ischemic Brain Injury After Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is the second most common cause of stroke and accounts for 8% to 15% of strokes in Western societies with an estimated incidence of 10 to 25 per 100 000 persons.1–3 Despite advances in the field of stroke and neurocritical care,4 the 30-day mortality has not changed significantly over the past 20 years.3 Indeed, ICH has the highest rates of dependence or death among stroke types and proven treatments are lacking. Clinical trials aimed at limiting hemorrhage growth, procoagulant agents for hemostasis,5 and surgical evacuation6 have not translated into improved clinical outcomes. Antihypertensive therapy for the purpose of reducing hematoma growth has been a mainstay of acute management. Guidelines recommend maintaining mean arterial pressure <130 mm Hg during the acute phase7; however, controversies exist given the lack of randomized clinical trial data and uncertainties about the rapidity and target level of blood pressure (BP)-lowering. Recent Phase 2 clinical trials evaluating acute BP control have shown promise in reducing hematoma expansion with an adequate safety profile and Phase 3 trials are underway.8,9 Besides hematoma growth, other pathophysiological processes occur in the setting of ICH and may serve as potential therapeutic targets. In the acute period after ICH, a rapid rise in intracranial pressure (ICP) from an expanding hematoma may reduce cerebral perfusion pressure. In this setting, interventions aimed at BP-lowering and hemostasis may theoretically induce thrombosis or exacerbate brain ischemia, particularly in patients with pre-existing cerebrovascular disease. A recent publication suggests that aggressive BP-lowering may actually cause acute brain ischemia and worsen outcomes after ICH.10 In this review, we outline the data on secondary acute ischemic injury after ICH, review the prevalence of remote ischemic lesions and risk factors associated with their occurrence, explore potential …

Safety of Temporary and Permanent Suspension of Antiplatelet Therapy After Drug Eluting Stent Implantation in Contemporary “Real‐world” Practice

To define the incidence of stent thrombosis (ST) and/or AMI (ST/AMI) associated with temporary or permanent suspension of dual antiplatelet therapy (DAPT) after coronary drug-eluting stent (DES) implantation in "real-world" patients, and additional factors influencing these events. Adherence to DAPT is critical for avoiding ST following DES implantation. However, the outcomes of patients undergoing antiplatelet therapy withdrawal following DES implantation remain to be clearly described. Patients receiving DES from 05/01/2003 to 05/01/2008 were identified from a single-center registry. Complete follow-up data were available for 5,681 patients (67% male, age 66 ± 11 years, duration 1,108 ± 446 days) who were included in this analysis. Uninterrupted DAPT was maintained in 4,070/5,681 (71.6%) patients, with an annual ST/AMI rate of 0.43%. Antiplatelet therapy was commonly ceased for gastrointestinal-related issues, dental procedures or noncardiac/nongastrointestinal surgery. Temporary DAPT suspension occurred in 593/5,681 (10.4%) patients for 17.6 ± 74.1 days, with 6/593 (1.0%) experiencing ST/AMI during this period. Of patients permanently ceasing aspirin (n = 187, mean 338 ± 411 days poststenting), clopidogrel (n = 713, mean 614 ± 375 days) or both agents (n = 118, mean 459 ± 408 days), ST/AMI was uncommon with an annual rate of 0.1-0.2%. Overall, independent predictors of ST/AMI were unstable initial presentation, uninterrupted DAPT and lower left ventricular ejection fraction. Factors predicting uninterrupted DAPT included diabetes, unstable presentation, prior MI, left main coronary PCI, and multivessel coronary disease. In real-world practice, rates of ST/AMI following DES implantation are low, but not insignificant, following aspirin and/or clopidogrel cessation. Use of uninterrupted DAPT appears more common in high-risk patients.

Dental Management of Antiplatelet-Receiving Patients: Is Uninterrupted Antiplatelet Therapy Safe?

The population of patients eligible for chronic antiplatelet treatment is expanding globally, in tandem with the rising prevalence of cardiovascular disease and the increasing use of percutaneous coronary interventions. While antiplatelet agents have revolutionized the management of atherosclerotic disease and its thrombotic complications, the potential of bleeding remains an inherent risk. Temporary withdrawal of antiplatelet therapy may therefore seem an attractive option in iatrogenic settings that pose a bleeding hazard; in this case, however, the benefit of averting antiplatelet-induced hemorrhage needs to be balanced against the risk of potentially fatal thrombosis, particularly in the expanding cohort of patients with drug-eluting stents (DES). Dental extractions represent the most frequent minor surgical procedures in the general population, yet the optimal dental management of antiplatelet-receiving patients is insufficiently explored. Sporadic cases of postextraction bleeding have been reported in the setting of continuous aspirin therapy, but reports of serious or life-threatening hemorrhage are extremely rare. Very few studies have systematically assessed the effect of aspirin or clopidogrel on the procedural outcome of dental treatment; these studies generally focused on the safety of dental procedures in the setting of uninterrupted antiplatelet monotherapy. The safety of dual antiplatelet therapy has been studied to an even lesser extent, and even these studies were limited by their retrospective design and by the small and heterogeneous patient populations. In the most comprehensive relevant report, Napenas et al included 29 patients receiving dual antiplatelet treatment and found a very low frequency of prolonged postextraction bleeding; however, the heterogeneity of the invasive procedures and the absence of a group of antiplatelet-naive controls limited the interpretation of their results. In light of the paucity of relevant studies, and particularly the absence of prospective investigations, defining a strategy to optimally balance the bleeding risk of uninterrupted antiplatelet therapy versus the thrombotic hazard of temporary antiplatelet withdrawal before dental procedures has been an unanswered question for a frequent clinical problem. Current recommendations suggest uninterrupted antiplatelet therapy in patients with DES undergoing dental procedures. In striking contrast to these recommendations, however, antiplatelet agents are frequently interrupted in everyday practice. This is clearly an empirical, rather than an evidence-based approach, based on excessive concerns about potential postextraction bleeding complications. Aiming to address this gap of evidence-based practice, the safety of dental extractions during uninterrupted single or dual antiplatelet treatment was recently assessed in a prospective fashion. In a study published in the American Journal of Cardiology, we included 643 patients referred for dental extractions. Of them, 42 (6.5%) were on clinically indicated daily low-dose aspirin, 36 (5.6%) were on clopidogrel, 33 (5.1%) were on both aspirin and clopidogrel, while 532 antiplatelet-naive patients served as controls. Treatment groups and controls were well matched clinically and received similar procedural treatment, thereby allowing for direct

The peri-operative management of anti-platelet therapy in elective, non-cardiac surgery

BackgroundCardiovascular complications are important causes of morbidity and mortality in patients undergoing elective non-cardiac surgery, with adverse cardiac outcomes estimated to occur in approximately 4% of all patients. Anti-platelet therapy withdrawal may precede up to 10% of acute cardiovascular syndromes, with withdrawal in the peri-operative setting incompletely appraised. ObjectivesThe aims of our study were to determine the proportion of patients undergoing elective non-cardiac surgery currently prescribed anti-platelet therapy, and identify current practice in peri-operative management. In addition, the relationship between management of anti-platelet therapy and peri-operative cardiac risk was assessed. MethodsWe evaluated consecutive patients attending elective non-cardiac surgery at a major tertiary referral centre. Clinical and biochemical data were collected and analysed on patients currently prescribed anti-platelet therapy. Peri-operative management of anti-platelet therapy was compared with estimated peri-operative cardiac risk. ResultsIncluded were 2950 consecutive patients, with 516 (17%) prescribed anti-platelet therapy, primarily for ischaemic heart disease. Two hundred and eighty nine (56%) patients had all anti-platelet therapy ceased in the peri-operative period, including 49% of patients with ischaemic heart disease and 46% of patients with previous coronary stenting. Peri-operative cardiac risk score did not influence anti-platelet therapy management. ConclusionsApproximately 17% of patients undergoing elective non-cardiac surgery are prescribed anti-platelet therapy, the predominant indication being for ischaemic heart disease. Almost half of all patients with previous coronary stenting had no anti-platelet therapy during the peri-operative period. The decision to cease anti-platelet therapy, which occurred commonly, did not appear to be guided by peri-operative cardiac risk stratification.

Liver transplantation with continued dual antiplatelet therapy

Liver transplantation in patients with dual antiplatelet therapy is considered high-risk procedure due to possible bleeding complications. However, withdrawal of antiplatelet therapy can lead to major adverse cardiac events such as stent thrombosis and even fatal myocardial infarction. We report on a 61-year-old male patient with nutritive toxic liver cirrhosis who underwent liver transplantation at our hospital in March 2010. Following two strokes he received secondary prophylaxis with aspirin and clopidogrel, which was continued at time of liver transplantation. The transplantation was performed successfully without withdrawal of the antiplatelet therapy. No cardiac event and no major bleeding complication occurred. This is, to our knowledge, the first report of a liver transplantation under dual antiplatelet therapy with aspirin and clopidogrel. It shows that even major procedures such as liver transplantation, with its associated high risk of surgical bleeding, can be safely performed with an appropriate risk.

Intraoperative Thrombosis of Right Coronary Artery Drug-Eluting Stent After 2 Years of Dual Antiplatelet Therapy

This study presents the case of intraoperative thrombosis of a right coronary drug-eluting stent and subsequent right heart ischemia more than 2 years poststent placement and after recent withdrawal of clopidogrel therapy. Dual antiplatelet therapy had been continued uninterrupted since placement until 7 days prior to surgery when clopidogrel was stopped. This case highlights the emerging evidence that drug-eluting stents are susceptible to late occlusive thrombosis on acute withdrawal of antiplatelet therapy. Right heart ischemia resolved with rapid intraoperative management and emergent cardiac catheterization. This emphasizes the necessity of immediate availability to cardiac interventional facilities, which can influence outcomes.

Is Withdrawal of Antiplatelet Therapy Necessary Prior to Skin Cancer Surgery

Is Withdrawal of Antiplatelet Therapy Necessary Prior to Skin Cancer Surgery

Angiographic and clinical outcome of invasively managed patients with thrombosed coronary bare metal or drug-eluting stents: the OPTIMIST study

Stent thrombosis (ST) is a major complication of percutaneous coronary interventions (PCIs). An invasive management by re-PCI is the commonly adopted treatment for ST, but data on outcome are limited. We performed a 2-year multicentre registry enrolling consecutive patients with angiographically confirmed ST undergoing PCI. The primary angiographic endpoint was optimal angiographic reperfusion (TIMI 3 + blush grade 2 or 3). The primary clinical endpoints were death and major adverse coronary and cerebrovascular events (MACCEs) at 6 months. A total of 110 patients underwent 117 urgent PCI during the study. Patients with drug-eluting stent (DES) thrombosis, compared with those with bare metal stent (BMS) thrombosis, exhibited a higher rate of late or very late presentation and of anti-platelet therapy withdrawal. Optimal angiographic reperfusion was obtained in 64% of the patients. Death and MACCE rates at 6 months were 17 and 30%, respectively. Clinical outcome was similar for BMS and DES thrombosis. Very late ST, implantation of stent during PCI for ST, and failure to achieve optimal angiographic reperfusion were the independent predictors of 6-month mortality. DES and BMS thromboses have different clinical features, but a similar poor outcome. Indeed, PCI for ST is associated with a low rate of reperfusion and to a high rate of death and MACCE, calling for action in order to prevent its occurrence and to improve its management.

Late thrombosis of paclitaxel-eluting stents: Long-term incidence, clinical consequences, and risk factors in a cohort of 604 patients

Late thrombosis is the major safety concern of drug-eluting stents, but its incidence in common clinical practice remains controversial to date, especially beyond the first year after stent implantation. We sought to investigate the incidence, clinical consequences, and risk factors of late thrombosis after drug-eluting stent implantation. Consecutive patients (N = 604) who received > or = 1 paclitaxel-eluting stent(s) (PES) between June 2003 and February 2005 at our institution were enrolled. Clinical characteristics and major outcomes were reviewed to detect cases and predictors of late and very late definite PES thrombosis (LDT) of PES, as currently defined by the Academic Research Council. During long-term follow-up (median 34.3 months, IQR 8.6), 17 cases of LDT were noted (cumulative incidence 2.8%, 95% CI 1.7%-4.5%). Most of LDT were very late thromboses (14 cases, 82%). Late and very late definite PES thrombosis appeared at a steady rate (incidence density 1.1% patient-years). Late and very late definite PES thrombosis was related to a high risk of all-cause death (HR 3.2, 95% CI 1.3-7.9) and cardiac death (HR 6.0, 95% CI 2.3-15.6). Withdrawal of antiplatelet therapy, left ventricular ejection fraction, and average stent diameter per patient were independent predictors of LDT in multivariate analysis. Late and very late definite PES thrombosis may be more frequent in a real setting than anticipated by initial experimental and observational studies but is keeping with more recent scientific evidence. It seems to occur at a constant rate during long-term follow-up and is associated with a high risk of overall and cardiac death.

Angioplasty for the late stent thrombosis, the new technical challenge: A single centre experience

Late Angiographic Stent Thrombosis (LAST) following drug-eluting stent is quite a well recognised entity today with most reported cases having occurred following antiplatelet therapy withdrawal late after stent implantation. Angioplasty of these late thrombotic stent occlusions poses a new technical challenge quite different from usual native vessel thrombotic occlusions, an issue that has not been addressed at length primarily due to the limited numbers and stray nature of the reports. We herein report our experience with percutaneous intervention in five such cases of late stent thrombosis > 2 years following drug-eluting stent implantation from a single centre.