Cath Lab Digest - April 2008 - (Page 32)

32 ASK THE EXPERT APRIL 2008 continued from previous page Therefore, a small number of the total patients were actually at increased risk. Of these patients under our analysis, around 88 percent did not develop stent thrombosis, even in the highest risk group. This model may help identify patients who will require even greater scrutiny with regards to antiplatelet therapy. Q A How important is adherence to dual-antiplatelet therapy in reducing the risk of stent thrombosis? According to our study, premature withdrawal from dual-antiplatelet therapy is the single highest predictor of stent thrombosis, along with acquired diabetes. In TAXUS Clinical Trials, clopidogrel or ticlopidine was administered pre-procedure and for a period of 6 months post procedure. The optimal duration of dualantiplatelet therapy, specifically clopidogrel, is unknown and DES thrombosis may still occur despite continued therapy. Data from several studies suggest that a longer duration of clopidogrel than was recommended post procedurally in drug-eluting stent pivotal trials (including TAXUS Clinical Trials) may be beneficial. According to the “2007 Focused Update of the ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention,” patients treated with DES should take a combination of aspirin and the clot-reducing drug clopidogrel for at least one year, and possibly longer, after stent implantation. How important is optimal stent expansion in helping to minimize the risk of stent thrombosis? We do not have much data on this. Earlier, when a patient developed stent thrombosis, frequently intravascular ultrasound (IVUS) showed a stent was poorly apposed or did not cover the full length of the disease. So, optimal stent expansion is important, however there are a lot of people with poor stent apposition who do not have stent thrombosis. This is still an unsettled issue as we believe that a lot of patients that have poor stent apposition don’t have stent thrombosis. This will require further study. Do you recommend the use of intravascular ultrasound (IVUS) technology to help optimize stent deployment? We’re using IVUS more and more to help ensure stents are optimally positioned. We use it now with approximately 50 percent of patients, compared to only 5 to 10 percent two years ago. I think IVUS is very important to help get a good angiographic result, which you often do not realize until you use this technology. What is your next step with this study? My hope is to expand the methodology and conduct a more in-depth analysis of the kinds of risk categories that were reported in the ARRIVE 1 and 2 Registries. The ARRIVE program helped to compile real-world usage of the TAXUS Stent in consecutively consented and treated patients. A follow-on study would seek to determine the frequency, timing and correlates (clinical, angiographic and IVUS) of stent thrombosis in DES patients and the relationship of aspirin and/or clopidogrel hyporesponsiveness, and general platelet reactivity to early and late stent thrombosis in DES patients. Plavix is a trademark of Sanofi-Aventis. According to the Directions for Use (DFU) of the TAXUS® Express2™ PaclitaxelEluting Coronary Stent System, it is very important that the patient is compliant with the post-procedural antiplatelet recommendations. Premature discontinuation of prescribed antiplatelet medication could result in a higher risk of thrombosis, myocardial infarction or death. Prior to Percutaneous Coronary Intervention (PCI), if a surgical or dental procedure is anticipated that requires early discontinuation of antiplatelet therapy, the interventional cardiologist and patient should carefully consider whether a drug-eluting stent and its associated recommended antiplatelet therapy is the appropriate PCI treatment choice. Following PCI, should a surgical or dental procedure be recommended that requires suspension of antiplatelet therapy, the risks and benefits of the procedure should be weighed against the possible risk associated with early discontinuation of antiplatelet therapy. Patients who require early discontinuation of antiplatelet therapy secondary to significant active bleeding should be monitored carefully for cardiac events and, once stabilized, have their antiplatelet therapy restarted as soon as possible per the discretion of their treating physicians. The Tigerwire’s unique feature of a gradual transition between a flexible tip to a stiff body makes it ideal to use as a specialty/workhorse wire in endovascular interventions. single core wire. The features that distinguish it from other 0.035 wires are its flexible tip and torquability with a stiff body. These features combine to make this wire a safe and effective tool in endovascular interventions. How does the Tigerwire compare to other available wires? The common wires used are the Wholey Wire, Angle Terumo, Magic Torque, and Zip Wire. All of these wires have application in peripheral intervention. The Tigerwire is a combination of the strengths of each wire. The tip is forgiving like a Wholey wire. The body has adequate stiffness. The torquability is comparable to the Angle Terumo and Zip Wires. It is not hydrophylic, so it is less prone to cause dissections. The transition zone enables the wire to traverse extreme angulations and the shapeable tip allows navigation through complex lesions. What about use of the wire for coronary procedures? The Tigerwire can be used in coronary procedures to deliver catheters and guides. Can you comment further on the timesavings you have experienced? Yes. In my opinion, the Tigerwire should be the first wire tried due to its features as described earlier. More than likely, it will be the only wire needed for superficial femoral artery (SFA) and iliac procedures. Any advice for labs that may be considering this wire? All labs should have the Tigerwire on the shelf. Its design features make it an essential wire. ■ The Tigerwire is available from St. Jude Medical (www.sjm.com). Dr. Krishnan can be contacted at prakash.krishnan@msnyuhealth.org Q A Q A Q A Correction: In the March 2008 issue, the American Registry of Diagnostic Medical Sonographers (ARDMS) was incorrectly spelled on page 82 of the article “An Extensive Set of Review Courses for the CCI Basic Science, NonInvasive Echocardiography and Vascular, and ARDMS Ultrasound Exams.” Cath Lab Digest regrets the error. Looking for the 2008 Cath Lab Digest Salary Survey? Find the link online at www.cathlabdigest.com’s home page. We invite you to write for Cath Lab Digest. Share your expertise and passion with thousands of fellow professionals across the country. All topics related to the cath lab are welcome. For more information and a copy of CLD author guidelines, email managing editor Rebecca Kapur at rkapur@hmpcommunications.com Sponsored and prepared by Boston Scientific Corporation http://www.sjm.com http://www.cathlabdigest.com

Table of Contents Feed for the Digital Edition of Cath Lab Digest - April 2008

Cath Lab Digest - April 2008 Kaiser San Rafael Medical Center Orbital Atherectomy: A New Treatment for Complex Peripheral Arterial Disease Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab Contents Clinical Editor’s Corner CEU Education Center The Missing Link in STEMI Interventions — Thrombus Aspiration during Primary Percutaneous Coronary Intervention Predicting Stent Thrombosis Using A Clinical Risk Score Use of a New Guidewire: The Tigerwire Should I Stay or Should I Go? Weighing Options for New Opportunities Navigating Tortuous Coronary Sinus Anatomy Using a Bipolar Lead The National Society of Radiology Practitioner Assistants (NSRPA) Holds 9th Annual Educational Conference For Medical Imaging Physician Extenders and Mid-Level Healthcare Providers Cath Lab & Beyond: A Meeting Update The Ten-Minute Interview with… Dale Hansen RT, CVT Sometimes, You Just Know Twin Circumflex Arteries: A Rare Coronary Artery Anomaly What Do You Think? Meetings Calendar News from the American College of Cardiology (ACC) Scientific Session and the Society of Cardiovascular Angiography & Interventions (SCAI) Annual Scientific Sessions in Partnership with the ACC i2 Summit Clinical & Industry News Cath Laughs Classifieds Advertisers Index

Cath Lab Digest - April 2008

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