Perioperative issues
Neeraj Sethi, R. James A. England, Neil de Zoysa in Head, Neck and Thyroid Surgery, 2020
The deployment of stents in the coronary vasculature requires antiplatelet cover to reduce the risk of stent thrombosis and myocardial infarction (MI) until the stent has undergone successful endothelialisation. The type of previous percutaneous coronary intervention (PCI) and stenting determines the minimum recommended duration of dual antiplatelet therapy (DAPT), and therefore may affect the timing of elective surgery. Cessation of DAPT prior to these timeframes represents an increased risk of perioperative in-stent thrombosis and acute MI, which is associated with greatly increased cardiovascular mortality: Bare metal stent (30 days)Drug-eluting stent (3–6 months, depending on product used; upper limit preferred)Balloon angioplasty (2 weeks or more) [11]
Complications of stenting for occlusive disease of aortic arch branches
Sachinder Singh Hans, Mark F. Conrad in Vascular and Endovascular Complications, 2021
Early experience with endovascular management of occlusive lesions of the arch vessels was favorable with initial success rates over 80% and 1–2 year recurrence rates that ranged from 8–25%.8 These outcomes were achieved with balloon angioplasty alone, and the addition of stenting to the procedure has shown improved patency rates in some series and primary stenting is favored by many authors, especially in cases involving highly calcified and complex lesions. A Cochrane review comparing primary angioplasty vs stenting for subclavian artery stenosis concluded that there was insufficient evidence to determine whether stenting was more effective.9 However, a meta-analysis of 8 studies with 544 patients that compared angioplasty alone to angioplasty and stenting found that the 1 year patency was superior with stent placement without additional complication rates.10 Ostial lesions tend to be an extension of aortic disease with heavy calcification, and balloon-expandable stents are favored over self-expanding stents here because of their higher radial force and more precise deployment. Conversely, self-expanding stents are useful when treating tortuous lesions away from the ostium and in vessels that have a variable diameter. The choice of a bare metal stent versus a covered stent graft remains controversial. Proponents of bare metal stents argue that they allow coverage of branch vessels without exclusion, especially in the innominate that branches early. Conversely, covered stents offer the theoretical advantage of complete decreased embolic potential by trapping all atherosclerotic debris and preventing future intimal hyperplasia, but to date, studies have had mixed results.11,12
Complex lower extremity revascularization
Peter A. Schneider in Endovascular Skills: Guidewire and Catheter Skills for Endovascular Surgery, 2019
If the aortic occlusion initiates in the middle or distal infrarenal aorta and there is runoff into some of the lumbar arteries, the risks are much less. In this setting, a large diameter self-expanding bare metal stent or covered stent could be used. Note that in this situation, the inferior mesenteric artery is frequently patent and it may be desirable to avoid a covered stent over this area. If the iliac arteries are also involved, the infrarenal stent is placed first and then bilateral wires, and bilateral iliac stents are placed to complete the reconstruction.
Computational model of stent-based delivery from a half-embedded two-layered coating
Published in Computer Methods in Biomechanics and Biomedical Engineering, 2020
Somnath Roy, Prashanta Kumar Mandal
Stent-based delivery to reopen blocked arteries and to prevent in-stent restenosis (ISR) following the implantation of bare-metal stent (BMS) has been resurrected recently (Acharya and Park 2006; Abraham et al. 2013; Bozsak et al. 2014; Katz et al. 2015; Mandal et al. 2016). The first-generation drug-eluting stent (DES) has a profound effect on reducing restenosis rates compared to BMS viz. 8.9% after eight months compared to 36.6% for BMS in the same study. The success of DES is usually associated with the effective delivery of potent therapeutics to the target site at a sufficient concentration for a sufficient time and in a biologically active state. Drug-eluting stents are now the primary choice for percutaneous coronary interventions implanted in millions of patients, but questions still arise regarding its longevity and safety (Hill et al. 2004; Venkatraman and Boey 2007). Clinical evidences show that the effectiveness of the delivery and the efficacy of drug immensely depend on the release rate, the diffusivity of drug, the spatial distribution of drug in the tissue, device design, local hemodynamic factors etc. (Lovich et al. 1998; Hwang and Edelman 2002; Yang and Burt 2006). It is much more necessary to study the relationships between the stent design and its appeasement/embedment, release and retention of eluted drug (Liistro and Bolognese 2003).
Role of proprotein convertase subtilisin/kexin type 9 inhibitors in patients with coronary artery disease undergoing percutaneous coronary intervention
Published in Expert Review of Cardiovascular Therapy, 2018
Eliano P. Navarese, Michalina Kołodziejczak, Aniela Petrescu, Bernhard Wernly, Michael Lichtenauer, Alexander Lauten, Antonino Buffon, Wojciech Wanha, Vincenzo Pestrichella, Gennaro Sardella, Gaetano Contegiacomo, Udaya Tantry, Kevin Bliden, Jacek Kubica, Paul A Gurbel
After the iterations in the PCI techniques, devices, and antithrombotic therapy, the occurrence stent thrombosis has significantly declined in the last years, but it still remains a catastrophic complication. While the introduction of drug-eluting stent (DES) contributed to the reduced rates of restenosis and revascularization compared to bare metal stent (BMS), a variety of factors related to its design including delayed stent endothelialization and hypersensitivity to its durable polymer, might have contributed to the development of stent thrombosis[27]. The antithrombotic therapy after DES implantation to prevent stent thrombosis consists of dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor. However, the antiischemic benefit is counterbalanced by a higher bleeding risk that is linearly related to the treatment duration[28]. Bleeding is a frequent complication in patients with CAD, especially those undergoing PCI[29] and is mainly attributable to the use of concomitant antithtrombotic regimens and procedural-related factors. Major bleeding has been proven independently associated in a stepwise fashion with the increase in both short-and long-term mortality[30,31]. Discontinuation of antithrombotic drugs following a bleeding event may equally lead to an increased rate of thrombotic events due to the progressive recovery of platelet function and coagulation activity. In addition, bleeding may provoke prothrombotic responses beyond those related to discontinuation of antithrombotic drugs[32].
Anti-thrombotic therapy strategies with long-term anticoagulation after percutaneous coronary intervention – a systematic review and meta-analysis
Published in Journal of Community Hospital Internal Medicine Perspectives, 2019
Waqas Javed Siddiqui, Muhammad Yasir Khan, Muhammad Shabbir Rawala, Kadambari Jethwani, Mohammad Harisullah Khan, Chikezie Alvarez, Ramsha Kashif, Syed Farhan Hasni, Sandeep Aggarwal, Andrew Kohut, Howard Eisen
In our analysis, there was a significantly decreased incidence of all-cause bleeding, TIMI major bleeding and TIMI minor bleeding in the DATT group as compared to the TATT group. These results are consistent with the results of individual RCTs and endorse that DAPT is safe as compared to TATT in patients who need long-term anticoagulation and also require concomitant antiplatelet therapy [19]. One cohort study found that the risk of bleeding with TATT was greatest within 30 days post-PCI [29]. Several studies have suggested that bleeding after PCI is an independent risk factor for mortality. This risk is even higher in patients who need red blood cell transfusion [30–32]. The current antithrombotic recommendation in high-risk patients for bleeding with atrial fibrillation undergoing PCI is to use single antiplatelet therapy (SAPT) with either VKA or NOAC (preferably NOAC) post stent placement. This recommendation further suggests discontinuing SAPT after one year if the patient remains at low risk for the thrombotic event. Patients with a high risk of thrombotic events should be given DAPT for at least 3– 6 months after stent placement. The duration of DAPT depends on the type of stent used, with three months for a bare-metal stent and six months for drug-eluting stents. Subsequently, SAPT should be continued for life unless the patient is at low risk of thrombotic events when SAPT can be discontinued after 12 months [33,34]. Before initiating either TATT or DATT, bleeding and thromboembolic risks should be ascertained using the CHA2DS2-VASc and the HAS-BLED scores to individualize the treatment strategy.
Related Knowledge Centers
- Angioplasty
- Coronary Stent
- Gastrointestinal Tract
- Restenosis
- Stent
- Drug-Eluting Stent
- Genous
- Percutaneous Coronary Intervention