Bleeding versus thrombosis: role of short DAPT in complex lesions.

Therapy with dual antiplatelet agents, defined as the combination of a platelet P2Y12 inhibitor and aspirin, is required to prevent thrombotic complications, after percutaneous coronary intervention (PCI) with stent implantation. Usually current guidelines recommend administration of dual antiplatelet therapy (DAPT) following percutaneous revascularization with drug-eluting stent (DES) for a period of at least 12 months or for 6 to 12 months in patients not at high risk. Nevertheless, the treatment of stable/unstable coronary artery disease with DES implantation increasing largely, the optimal duration of DAPT is still unclear. The duration of DAPT after coronary stenting has been evaluated in recent randomized studies with conflicting results. The administration of long period of DAPT is a strategy to reduce thrombosis events but largely increase the hemorrhagic ones. Otherwise, shorter DAPT period is protective about bleeds with consequently increased ischemic events. In addition, as new DES carry a lower risk of stent thrombosis (ST) compared with the first-generation DES and possibly even bare-metal stents, a shift toward better protection from ST may have an effect on the duration and the intensity of DAPT. Whether the duration of DAPT should be shorter or longer than the currently recommended 6 to 12 months is analyzed in this review, drawing on results from the most recent studies and meta-analysis.

Results of the self-expandable BA9 stent for treatment of large angle coronary bifurcation.

Since the advent of coronary angioplasty the treatment of bifurcation lesions has always proved a complex issue resulting in lower angiographic success rates, increased risk of restenosis, higher rates of dissection, myocardial infarction, and acute vessel closure. The advent of coronary stenting reduced the risks, but in-stent restenosis was noted to be frequent at the ostium of the side branch; for this reasons two-stent techniques were developed to try to combat this phenomenon. Novel dedicated stents have recently been developed to provide easier access to the SB and to scaffold more effectively its ostium, matching the stent configuration more closely to the anatomy of the bifurcation. Most of bifurcation lesions that require treatment and which have a wide angle involving the left main coronary artery (LMCA). The impact of the angle and the asymmetry of bifurcation on flow dynamic are very important and may influence clinical outcome. More recently, percutaneous coronary intervention (PCI) to treat wide angle disease has increased in frequency, and is associated with improvements in interventional techniques and adjunctive drug therapy. Several studies have shown that stenting in LMCA, especially using drug-eluting stents (DES), is a safe and effective treatment strategy both at mid- and long-term follow-up. The AXXESS System is a self-expanding, conically-shaped stent from nitinol (nickel-titanium alloy) with strut thickness, specifically designed to conform to the anatomy at the level of the bifurcation carina. A special version of the AXXESS System has been designed for left main bifurcation lesions, allowing for larger diameters (up to 4.75 mm) and distinct bifurcation angles (flare-end diameters of 8, 10 and 12 mm). The AXXENT trial is the first study to evaluate the vascular response of the self-expanding biolimus-eluting AXXESS stent for the treatment of LMCA bifurcation lesions. It was designed to evaluate the safety and efficacy of the AXXESS biolimus-eluting stent for the treatment of LMCA bifurcation lesions, that showed good results in terms of stent thrombosis and TLR at 6 months follow-up. Technical modifications and stent innovations may further improve both the angiographic and clinical outcomes for patients with wide angle bifurcation disease treated by PCI. Moreover a long term follow-up is needful to demonstrate better safety and efficacy of these new dedicated bifurcation devices.

Do angle and anatomy influence outcomes in bifurcation stenting?

Coronary bifurcation lesions are regarded as complex and their treatment is still the subject of substantial debate. Important elements to consider before approaching a bifurcation include angle and anatomy, in particular the take off angle (proximal angle, A) that is between the proximal MB and SB and the carina angle (distal angle, B) that is between distal main branch (MB) and side branch (SB) and also the extent and distribution of disease on the side branch and its size. Many techniques have been used to treat coronary bifurcation lesions such as provisional stenting or double stenting but no consensus technique has been accepted primarily due to variation of disease severity, angle and anatomy. Angle B is the unique statistically significant independent predictor factor influencing outcomes. Bifurcation angle and anatomy are important predictors of short and long-term outcomes after bifurcation treatment. Moreover we should evaluate it after wiring MB and SB so as after pre-dilatation because of side branch access and carina area angle anatomy variation and plaque shift. Should be investigated if the developing of new dedicated devices for bifurcation lesions could mix the advantages of one and two-stent techniques.

['Incidentaloma' in inguinal hernia surgery]. / 'Incidentaloma' nella chirurgia dell'ernia inguinale.

Adult Granulosa-Cell Tumor (GCT) is an uncommon ovarian malignancy. The clinical course is characterized by slow growth with late recurrence. A variety of clinical and pathologic parameters have previously been evaluated for prognosis with inconclusive results. The aim of this study was to report a case of a granulosa-cell tumor of the ovary that recurred 25 years after first surgery. The clinical course and histopathology of the case were reviewed and a literature search for other reported cases was performed.

[Hyperhomocysteinemia and thrombosis: clinical case and literature's review]. / Iperomocisteinemia e trombosi: caso clinico e revisione della letteratura.

Patients with homocystinuria have an increased risk for both venous and artherial thrombosis but it has been found that even moderate increase in homocysteine levels are associated with heightened risk of thromboembolism. The Authors report a case of juvenile vasculopathy in a patient with hyperomocysteinemia. In this case the patient presented both venous and artherial thromboembolism in the absence of the most important risk factors. The opportunity is stressed to perform clinical tests for the correct diagnosis of hyperhomocysteinemia because it is possible, with the use of folic acid and vitamin B12, to correct the elevated levels of homocysteine.