Superficial femoral artery pseudoaneurysm at implantation site of drug eluting stent discovered due to bacteremia:A case report

BACKGROUND Drug-eluting stents(DES)are used to treat lower extremity arterial disease.During DES treatment,aneurysmal degeneration occasionally occurs,especially with fluoropolymer-based DES.However,the incidence of pseudoaneurysms after DES placement is rarely reported in the lower extremity region,although there have been several reports on pseudoaneurysm formation after DES placement in the coronary artery region.CASE SUMMARY We report the case of a 64-year-old man who presented with fever and pain in his left hand after dialysis.Bacteremia was diagnosed by blood culture,and after admission,he developed pain on the medial side of the right thigh.A pseudoaneurysm was observed in the right superficial femoral artery(SFA)at the proximal end of a previously placed DES.The bacteremia was thought to have been caused by a pseudoaneurysm of the left superficial brachial artery,and the pseudoaneurysm of the left superficial brachial artery was removed after antibiotic treatment.The pseudoaneurysm of the right SFA rapidly expanded after admission,but the expansion rate was reduced after infection control.Seven months after the first admission,the pseudoaneurysm of the left SFA was re-moved and in situ revascularization performed using a rifampicin-soaked Dacron graft.CONCLUSION Although pseudoaneurysm after DES placement in the lower extremity region is rare,it must be considered in patients with bacteremia.

Advantages and disadvantages of biodegradable platforms in drug eluting stents

Coronary angioplasty with drug-eluting stent(DES)implantation is currently the most common stent procedure worldwide.Since the introduction of DES,coronary restenosis as well as the incidence of target vessel and target lesion revascularization have been significantly reduced.However,the incidence of very late stent thrombosis beyond the first year after stent deployment has more commonly been linked to DES than to baremetal stent(BMS)implantation.Several factors have been associated with very late stent thrombosis after DES implantation,such as delayed healing,inflammation,stent mal-apposition and endothelial dysfunction. Some of these adverse events were associated with the presence of durable polymers,which were essential to allow the elution of the immunosuppressive drug in the first DES designs.The introduction of erodable polymers in DES technology has provided the potential to complete the degradation of the polymer simultaneously or immediately after the release of the immunosuppressive drug,after which a BMS remains in place.Several DES designs with biodegradable(BIO)polymers have been introduced in preclinical and clinical studies, including randomized trials.In this review,we analyze the clinical results from 6 observational and randomized studies with BIO polymers and discuss advantages and disadvantages of this new technology.

Drug-eluting fully covered self-expanding metal stent for dissolution of bile duct stones in vitro

BACKGROUND The treatment of difficult common bile duct stones(CBDS)remains a big challenge around the world.Biliary stenting is a widely accepted rescue method in patients with failed stone extraction under endoscopic retrograde cholangiopancreatography.Fully covered self-expanding metal stent(FCSEMS)has gained increasing attention in the management of difficult CBDS.AIM To manufacture a drug-eluting FCSEMS,which can achieve controlled release of stone-dissolving agents and speed up the dissolution of CBDS.METHODS Customized covered nitinol stents were adopted.Sodium cholate(SC)and disodium ethylene diamine tetraacetic acid(EDTA disodium,EDTA for short)were used as stone-dissolving agents.Three different types of drug-eluting stents were manufactured by dip coating(Stent I),coaxial electrospinning(Stent II),and dip coating combined with electrospinning(Stent III),respectively.The drugrelease behavior and stone-dissolving efficacy of these stents were evaluated in vitro to sort out the best manufacturing method.And the selected stonedissolving stents were further put into porcine CBD to evaluate their biosecurity.RESULTS Stent I and Stent II had obvious burst release of drugs in the first 5 d while Stent III presented controlled and sustainable drug release for 30 d.In still buffer,the final stone mass-loss rate of each group was 5.19%±0.69%for naked FCSEMS,20.37%±2.13%for Stent I,24.57%±1.45%for Stent II,and 33.72%±0.67%for Stent III.In flowing bile,the final stone mass-loss rate of each group was 5.87%±0.25%for naked FCSEMS,6.36%±0.48%for Stent I,6.38%±0.37%for Stent II,and 8.15%±0.27%for Stent III.Stent III caused the most stone mass-loss no matter in still buffer or in flowing bile,which was significantly higher than those of other groups(P<0.05).In vivo,Stent III made no difference from naked FCSEMS in serological analysis(P>0.05)and histopathological examination(P>0.05).CONCLUSION The novel SC and EDTA-eluting FCSEMS is efficient in diminishing CBDS in vitro.When conventional endoscopic techniques fail to remove difficult CBDS,SC and EDTA-eluting FCSEMS implantation may be considered a promising alternative.

Drug-eluting stents and acute myocardial infarction:A lethal combination or friends?

Primary percutaneous coronary intervention is the preferred reperfusion strategy for patients presenting with ST-segment elevation myocardial infarction(STEMI). First generation drug-eluting stents(DES),(sirolimus drug-eluting stents and paclitaxel drug-eluting stents), reduce the risk of restenosis and target vessel revascularization compared to bare metal stents. However, stent thrombosis emerged as a major safety concern with first generation DES. In response to these safety issues, second generation DES were developed with different drugs, improved stent platforms and more biocompatible durable or bioabsorbable polymeric coating. This article presents an overview of safety and efficacy of the first and second generation DES in STEMI.

Drug-eluting balloons versus new generation drug-eluting stents for the management of in-stent restenosis: an updated meta-analysis of randomized studies

Background New-generation drug-eluting stents (DES) was more effective in the treatment of in-stent restenosis (ISR) compared with the first-generation DES. Drug-eluting balloons (DEB) and new-generation DES had been available strategies in treatment of bare-metal stents/DES ISR (BMS/DES-ISR). Six new randomized trials have recently examined the angiographic outcomes and one-year clinical outcomes of DEB and new generation DES in BMS/DES-ISR. However, the optimal management for BMS/DES-ISR lesions remains controversial. Methods We searched the randomized clinical trials evaluating the angiographic outcomes and one-year clinical outcomes of DEB and new-generation DES in patients with BMS/DES-ISR. The primary endpoints were the angiographic outcomes, including the minimal luminal diameter (MLD), diameter stenosis %(DS%), late lumen loss (LLL), and binary restenosis (BR). Results A total of six randomized clinical trials with 1177 BMS/DES-ISR patients were included in our meta-analysis. For angiographic outcomes, there were significantly less MLD and more DS% with DEB compared to new-generation DES (MLD: MD =?0.18, 95% CI:?0.31– ?0.04, P < 0.001;DS%: MD = 5.68, 95% CI: 1.00–10.37, P < 0.001). Moreover, for one-year clinical outcomes, DEB was associated with a significant increase risk in target lesion revascularization (TLR)(RR = 2.93, 95% CI: 1.50–5.72, P = 0.002). However, DEB was associated with higher risks of major adverse cardiac event, target vessel revascularization, TLR, BR, and more DS% only in DES-ISR group. Conclusions DEB and new-generation DES have the similar clinical efficacy for the treatment of BMS-ISR. However, DES showed more MLD, less DS%, and a decreased risk of TLR for the treatment of DES-ISR.

Five-year clinical outcomes of first-generation versus second-generation drug-eluting stents following coronary chronic total occlusion intervention

Background There are limited data comparing long-term clinical outcomes between first-generation (1G) and second-generation (2G) drug-eluting stents (DESs) in patients who underwent successful percutaneous coronary intervention (PCI) for coronary chronic total occlusion (CTO) lesion. Methods A total of 840 consecutive patients who underwent PCI with DESs for CTO lesion from January 2004 to November 2015 were enrolled. Finally, a total of 324 eligible CTO patients received 1G-DES (Paclitaxel-eluting stent or Sirolimus-eluting stent, n = 157) or 2G-DES (Zotarolimus-eluting stent or Everolimus-eluting stent, n = 167) were enrolled. The clinical endpoint was the occurrence of major adverse cardiac events (MACE) defined as all-cause death, recurrent myocardial infarction (re-MI), total repeat revascularization [target lesion revascularization (TLR), target vessel revascularization (TVR), and non-TVR]. We investigated the 5-year major clinical outcomes between 1G-DES and 2G-DES in patient who underwent successful CTO PCI. Results After propensity score matched (PSM) analysis, two well-balanced groups (111 pairs, n = 222, C-statistic = 0.718) were generated. Up to the 5-year follow-up period, the cumulative incidence of all-cause death, re-MI, TLR, TVR and non-TVR were not significantly different between the two groups. Finally, MACE was also similar between the two groups (HR = 1.557, 95% CI: 0.820–2.959, P = 0.176) after PSM. Conclusions In this study, 2G-DES was not associated with reduced long-term MACE compared with 1G-DES following successful CTO revascularization up to five years.

Therapeutic effect of rotational atherectomy with implantation of drug eluting stent in heavily coronary calcified patients

BackgroundRotational atherectomy (RA ) 能在重重地冠的钙化的病人便于经皮的冠的干预(一种总线标准) 。这种技术的有效性和安全需要是进一步的 evaluated.Methods &；从 2011 年 9 月在我们的中心经历了 RA 到 2014 年 6 月的 ResultsEighty 病人被注册。吝啬的年龄是 72.4 ±；10.4 年。左室的喷射部分(LVEF ) 是一般水准 52.3%±；8.48% 并且估计的 glomerular 过滤率是 73.2 ±；3.20 mL/min 每 1.73 m 2 。冠的损害是复杂的，与句法 20 29.5 ±；9.86。参考容器的直径是 3.4 ±；0.45 公里和目标容器的平均直径狭窄是 80%±；10% 。所有病人在 RA 以后成功地与药 eluting stents (DES ) 被部署。病人被跟随在上面为 12-18 月。Kaplan-Meier 阴谋估计幸存率是 93.4% ，主要不利心脏、服的事件(MACCE ) 的累积发生是 25.4% 。流血并且程序相关的复杂并发症是相当低的。为 multivariate 分析的艇长比例的危险模型证明糖尿病， LVEF 和 postdilatation 的最大的压力是 DES 的培植跟随的 MACCE.ConclusionsRA 的预言者为重重地冠的钙化的病人有效、安全。糖尿病， LVEF 和 postdilatation 的最大的压力为 MACCE 是预兆的。

Nine-year clinical outcomes of drug-eluting stents vs. bare metal stents for large coronary vessel lesions

sTo 与大冠的 vessels.MethodsFrom 2004年4月为病人与赤裸金属的 stents ( BMS )相比评估 drug-eluting stents ( DES )的长期的安全和有效性到2006年10月， 2407 个连续病人经历 de novo 损害有比大或等于在在中国北京的 Fu Wai 医院的 3.5 公里的参考容器直径的经皮的冠的干预，有希望地被注册进这研究。我们包括死亡，心肌的梗塞(MI ) ，血栓，目标损害 revascularization (TLR ) ，目标容器 revascularization (TVR ) ，和主要不利心脏的事件获得了 9 年的临床的结果(向，死亡， MI，和 TVR 合成) 。我们执行了艇长比例危险的模型在倾向 match.ResultsAfter 倾向得分以后估计所有结果措施的相对风险， 514 个对待 DES 的病人被匹配到 514 个对待 BMS 的病人。与 BMS 对待的病人与 TLR 的更高的风险被联系(HR：2.55， 95%CI：1.520-4.277， P = 0.0004 ) 并且 TVR (HR：1.889， 95%CI：1.185-3.011， P = 0.0075 ) ，但是 death/MI 和向的率不是统计上不同的。所有学术研究协会定义 stent 血栓在 9 年在二 groups.ConclusionsDuring 是可比较的整个九年的长期的后续，在有大冠的动脉的病人的 DES 的使用仍然在 TLR 和 TVR 的风险与重要减小被联系。

Duration of dual antiplatelet treatment in the era of next generation drug-eluting stents

Current percutaneous coronary intervention guidelines recommend dual antiplatelets(aspirin 100 mg + clopidogrel 75 mg daily) for at least 12 mo following drugeluting stent(DES) implantation if patients are not at high risk of bleeding.Several reports have tried to shorten the dual antiplatelet therapy to 3-6 mo,especially following next-generation DES implantation,for cost-effectiveness.However,the clinical results are inconsistent and the data regarding next-generation DESs limited.In this report,recently published important pivotal reports regarding the optimal duration of dual antiplatelets following DES implantation are summarized.

Long term outcomes of drug-eluting stent versus coronary artery bypass grafting for left main coronary artery disease： a meta-analysis

BackgroundIt 仍然是争论的有 drug-eluting stent ( DES )的经皮的冠的干预是否与冠的动脉相比安全、有效为没有防卫的左主要冠的动脉( ULMCA )绕过接枝外科( CABG )疾病在长期列在后面在上面( 3 年) .MethodsEligible 研究被寻找 PubMed 选择， EMBASE ，并且 Cochrane 图书馆直到2016年12月6日。主要端点是一死亡，心肌的梗塞(MI ) 或在最长的后续期间的击合成。死亡，心脏的死亡， MI，击和重复 revascularization 是第二等的 outcomes.ResultsFour 使随机化的控制试用和包含 14,130 个病人的 12 调整观察研究被包括。DES 比得上关于主要端点的出现的 CABG (HR = 0.94， 95% CI：0.86-1.03 ) 。而且， DES 显著地与 MI 的更高的发生被联系(HR = 1.56， 95% CI：1.09-2.22 ) 并且重复 revascularization (HR = 3.09， 95% CI：2.33-4.10 ) 当没有差别在二策略之间被发现时，与 CABG 相比认为是死亡，心脏的死亡和击的率。而且， DES 能减少死亡， MI 或击的合成端点的风险(HR = 0.80， 95% CI：0.67-0.95 ) 因为有句法的 ULMCA 损害与重复 revascularization 的更高的风险获得 32 .ConclusionsAlthough，有 DES 的一种总线标准看起来象为 ULMCA 疾病在的 CABG 一样安全长期列在后面起来。另外，有 DES 的治疗能是到为 ULMCA 损害与的 CABG 的其他的 interventional 策略对中间的解剖复杂性低。

Revisiting endovascular treatment in below-the-knee disease. Are drug-eluting stents the best option？

Patients with below-the-knee arterial disease are primarily individuals suffering from critical limb ischemia(CLI), while a large percentage of these patients are also suffering from diabetes or chronic renal failure or both. Available data from randomized controlled trials and their meta-analysis demonstrated that the use of infrapopliteal drug-eluting stents(DES), in short-to medium-length lesions, obtains significantly better results compared to plain balloon angioplasty and bare metal stenting with regards to vascular restenosis, target lesion revascularization, wound healing and amputations. Nonetheless, the use of this technology in every-day clinical practice remains limited mainly due to concerns regarding the deployment of a permanent metallic scaffold and the possibility of valid future therapeutic perspectives. However, in the majority of the cases, these concerns are not scientifically justified. Large-scale, multicenter randomized controlled trials, investigating a significantly larger number of patients than those already published, would provide more solid evidence and consolidate the use of infrapopliteal DES in CLI patients. Moreover, there is still little evidence on whether this technology can be as effective for longer below-the-knee lesions, where a considerable number of DES is required. The development and investigation of new, longer balloon-expanding or perhaps selfexpanding DES could be the answer to this problem.

Biodegradable polymer stents vs second generation drug eluting stents:A meta-analysis and systematic review of randomized controlled trials

AIM: To evaluate the premise, that biodegradable polymer drug eluting stents(BD-DES) could improve clinical outcomes compared to second generation permanent polymer drug eluting stents(PP-DES), we pooled the data from all the available randomized control trials(RCT) comparing the clinical performance of both these stents.METHODS: A systematic literature search of Pub Med, Cochrane, Google scholar databases, EMBASE, MEDLINE and SCOPUS was performed during time period of January 2001 to April 2015 for RCT and comparing safety and efficacy of BD-DES vs second generation PP-DES. The primary outcomes of interest were definite stent thrombosis, target lesion revascularization, myocardial infarction, cardiac deaths and total deaths during the study period. RESULTS: A total of 11 RCT's with a total of 12644 patients were included in the meta-analysis, with 6598 patients in BD-DES vs 6046 patients in second generation PP-DES. The mean follow up period was 16 mo. Pooled analysis showed non-inferiority of BD-DES, comparing events of stent thrombosis(OR = 1.42, 95%CI: 0.79-2.52, P = 0.24), target lesion revascularization(OR = 0.99, 95%CI: 0.84-1.17, P = 0.92), myocardial infarction(OR = 1.06, 95%CI: 0.86-1.29, P = 0.92), cardiac deaths(OR = 1.07, 95%CI 0.82-1.41, P = 0.94) and total deaths(OR = 0.96, 95%CI: 0.80-1.17, P = 0.71).CONCLUSION: BD-DES, when compared to second generation PP-DES, showed no significant advantage and the outcomes were comparable between both the groups.

Major clinical and angiographic outcome of drug eluting stents in native ostial coronary artery disease

Objectives: The study was designed to evaluate the efficacy and safety of drug eluting stents (DESs) in aorto-ostial (A-O) coronary artery lesions, in terms of early and late restenosis rate;including clinical assessment, non-invasive stress testing and angiographic follow-up. Also, the study was aimed to compare the results of implantation of drug eluting stents (DES) to that of bare metal stents (BMS) in aortoostial lesions done over a previous 5 years in Royal Brompton Hospital. Background: The safety and effectiveness of DESs for the treatment of aortoostial lesions. Methods: We included 161 consecutive patients with symptoms subjective of angina pectoris or objective evidence of myocardial ischemia;who underwent percutaneous coronary interventions (PCI) in coronary ostial lesions using DES. The patients were divided into two groups based on the site of ostial lesion. The control group consisted of 125 consecutive patients who underwent percutaneous coronary intervention for ostial lesions using bare metal stents (BMS) implantation in the period immediately before the introduction of DES. The incidence of major adverse cardiac events (MACE), including death or Q-wave myocardial infarction (MI), need for repeated revascularization procedure CABG or angioplasty, were recorded in-hospital and at twelve months ± 3 months. Follow-up angiography was only performed in case of recurrent symptoms subjective of myocardial ischemia or if there was objective evidence of myocardial ischemia by stress testing. Results: The initial procedure was successful in 149 patients (92.5%) in the DES arm. There were no statistically significant major in-hospital complications in the DES group, compared to BMS group which showed 4 cases of in-hospital deaths (p = 0.017). At Twelve months ± 3 months follow-up, MACE were significantly less frequent in the DES group compared to the BMS group, including death (0.8% vs. 6.4%, p = 0.004) and need for CABG (1.7% vs. 10%, p = 0.012). Conclusions: The main finding of our study is that, compared to the BMS, implantation of the DES in coronary ostial lesions appears safe and effective. It is associated with high procedural success rate, low immediate and in-hospital complication rate, infrequent late adverse events and favourable long-term clinical and angiographic outcomes compared with bare metal stents implantation at 12-month follow-up. Advanced age, previous myocardial infarction and acute coronary syndromes at presentation were all found to be independent positive predictors for clinical events after drug eluting stent implantation in ostial lesions.

Successful Percutaneous Treatment of Coronary Artery Ectasia with Drug-Eluting Stent

Coronary artery ectasia is well-known but relatively uncommon finding with prevalence ranging from 1.2% to 5.3%. Coronary artery ectasia has been associated with atherosclerosis in approximately half of the cases. Here, we are presenting a case of male patient who experienced myocardial infarction and was diagnosed with coronary artery ectasia in proximal-mid junction of left anterior descending artery with stenotic lesion. The patient was successfully treated with percutaneous transluminal coronary angioplasty.

Intracoronary brachytherapy for the treatment of recurrent drugeluting stent in-stent restenosis:A systematic review and metaanalysis

BACKGROUND We performed a meta-analysis on observational studies since randomized control trials are not available.We studied intracoronary brachytherapy(ICBT)and recurrent drug eluting stent in-stent restenosis(DES-ISR)to evaluate the procedural success,target lesion revascularization(TLR),incidence of myocardial infarction(MI)and all-cause mortality at 2 years follow-up.AIM To perform meta-analysis for patients undergoing ICBT for recurrent DES-ISR.METHODS We performed a systematic search of the PubMed/MEDLINE,Cochrane and DARE databases to identify relevant articles.Studies were excluded if intracoronary brachytherapy was used as a treatment modality for initial ISR and studies with bare metal stents.We used a random-effect model with DerSimonian&Laird method to calculate summary estimates.Heterogeneity was assessed using I2 statistics.RESULTS A total of 6 observational studies were included in the final analysis.Procedural angiographic success following intra-coronary brachytherapy was 99.8%.Incidence of MI at 1-year was 2%and 4.1%at 2-years,respectively.The incidence of TLR 14.1%at 1-year and 22.7%at 2-years,respectively.All-cause mortality at 1-and 2-year follow-up was 3%and 7.5%,respectively.CONCLUSION Given the observational nature of the studies included in the analysis,heterogeneity was significantly higher for outcomes.While there are no randomized controlled trials or definitive guidelines available for recurrent ISR associated with DES,this analysis suggests that brachytherapy might be the alternative approach for recurrent DES-ISR.Randomized controlled trials are required to confirm results from this study.

Immediate and mid-term outcomes of drug-eluting stent in treatment of coronary artery stenosis with very long defuse lesions

Objectives To evaluate the feasibility, and immediate and mid-term outcomes of drug-eluting stents (DESs) in the treatment of coronary artery stenosis with very long defuse lesions(VLDL). Methods Inclusion criteria:

Volumetric intravascular ultrasound comparisons of drug-eluting stent thrombosis and in-stent restenosis

Objectives We compared intravascular ultrasound (IVUS) findings of drug-eluting stent (DES)-treated lesions that developed stent thrombosis versus in-stent restenosis (ISR) to identify underlying mechanical differences. Methods IVUS findings in 15 post-DES thrombosis patients were compared with 45 matched ISR patients who had no evidence of stent thrombosis. Results Minimum stent area [MSA, (3.7±0.8) mm2 vs (4.9±1.8) mm2, P=0.01], minimum stent diameter [(1.9±0.3) mm vs (2.3±0.4) mm, P=0.005], mean stent area [(5.2±0.8) mm2 vs (7.2±2.1) mm2, P【0.01], and both focal [MSA/reference lumen area, (54.7±15.9)% vs (75.0±20.1)%, P=0.001] and diffuse stent expansion [mean stent area/reference lumen area, (76.6±23.0)% vs (110.3±23.3)%, P【0.01] were significantly smaller in the stent thrombosis group (vs the ISR group). An MSA 【4.0 mm2 (73.3% vs 35.6%, P=0.01) or 【5.0 mm2 (86.7% vs 53.3%, P=0.02) was more often found in the stent thrombosis group (vs the ISR group). The MSA site occurred more frequently in the proximal stent segment within the stent thrombosis group compared to the ISR group (60% vs 24.4%, P=0.01). There were no differences in edge dissection, stent fracture, or stent-vessel wall malapposition between the two groups. Independent predictors of stent thrombosis were diffuse stent expansion (OR=1.5, P=0.03) and proximal location of the MSA site (OR=12.7, P=0.04). Conclusion DES-treated lesions that develop thrombosis or restenosis are often underexpanded. Underexpansion appears to be more severe in DES-thrombosis lesions. Lesions with diffuse underexpansion and a proximal (vs distal) underexpanded MSA site are more predisposed to thrombus formation than ISR.

Intravascular ultrasound assessment of the incidence and predictors of edge dissections and intramural hematomas after drug-eluting stent implantation

Objective We used intravascular ultrasound (IVUS) to assess incidence, predictors, morphology, and angiographic findings of edge dissections and intramural hematomas after drug-eluting stent (DES) implantation. Methods We studied 887 patients with 1 045 non-in-stent restenosis lesions in 977 native arteries undergoing DES implantation with IVUS imaging, and compared the dissected stent end to the non-dissected stent end. Results Eighty-two dissections were detected; 51.2% (42/82) involved the proximal and 48.8% (40/82) the distal stent edge. When compared to the non-dissected stent end, residual plaque area [(8.0±4.3) mm2 vs (5.2±3.0) mm2, P【0.01], plaque burden [(52±12)% vs (36±15)%, P【0.01], plaque eccentricity (8.4±5.5 vs 4.0±3.4, P【0.01), and stent edge symmetry (1.17±0.11 vs 1.14±0.08, P=0.02) were larger; plaque burden≥50% was more frequent (62% vs 17%, P【0.01) and calcium deposits (52.5% vs 35.6%, P=0.03) more common; and the lumen/stent area (0.86±0.16 vs 1.02±0.18, P【0.01) was smaller in the stent dissected end. Independent predictors of stent edge dissection were residual plaque eccentricity (OR=1.3, P【0.01) and residual plaque burden≥50% (OR=7.3, P【0.01). Intramural hematomas occurred in 34.1% (28/82) of dissections.Independent predictors of intramural hematomas were plaque eccentricity (OR=1.4, P=0.005), plaque burden≥50% (OR=7.1, P=0.02), and mean lumen diameter to stent diameter ratio (OR=0.37, P=0.04).Concluslon IVUS identified edge dissections after 9.4% of DES implantations. Residual plaque eccentricity and significant plaque burden predicted coronary stent edge dissections. Dissections in less diseased reference segments with an arc of normal vessel wall (greater plaque eccentricity) more often evolved into an intramural hematoma.

Organ transplantation and drug eluting stents:Perioperative challenges

Patients listed for organ transplant frequently have severe coronary artery disease(CAD), which may be treated with drug eluting stents(DES). Everolimus and zotarolimus eluting stents are commonly used. Newer generation biolimus and novolimus eluting biodegradable stents are becoming increasingly popular. Patients undergoing transplant surgery soon after the placement of DES are at increased risk of stent thrombosis(ST) in the perioperative period. Dual antiplatelet therapy(DAPT) with aspirin and a P2Y12 inhibitor such as clopidogrel, prasugrel and ticagrelor is instated post stenting to decrease the incident of ST. Cangrelor has recently been approved by Food and Drug Administration and can be used as a bridging antiplatelet drug. The risk of ischemia vs bleeding must be considered when discontinuing or continuing DAPT for surgery. Though living donor transplant surgery is an elective procedure and can be optimally timed, cadaveric organ availability is unpredictable, therefore, discontinuation of antiplatelet medication cannot be optimally timed. The type of stent and timing of transplant surgery can be of utmost importance. Many platelet function point of care tests such as Light Transmittance Aggregrometry, Thromboelastography Platelet Mapping, VerifyN ow, Multiple Electrode Aggregrometry are used to assess bleeding risk and guide perioperative platelet transfusion. Response to allogenic platelet transfusion to control severe intraoperative bleeding may differ with the antiplatelet drug. In stent thrombosis is an emergency where management with either a drug eluting balloon or a DES has shown superior outcomes. Post-transplant complications often involved stenosis of an important vessel that may need revascularization. DES are now used for endovascular interventions for transplant orthotropic heart CAD, hepatic artery stenosis post liver transplantation, transplant renal artery stenosis following kidney transplantation, etc. Several antiproliferative drugs used in the DES are inhibitors of mammalian target of rapamycin. Thus they are used for post-transplant immunosuppression to prevent acute rejection in recipients with heart, liver, lung and kidney transplantation. This article describes in detail the various perioperative challenges encountered in organ transplantation surgery and patients with drug eluting stents.