Comparison of Ticagrelor Versus Clopidogrel on Cerebrovascular Microembolic Events and Platelet Inhibition during Transcatheter Aortic Valve Implantation.

The impact of the antiplatelet regimen and the extent of associated platelet inhibition on cerebrovascular microembolic events during transcatheter aortic valve implantation (TAVI) are unknown. Our aim was to evaluate the effects of ticagrelor versus clopidogrel and of platelet inhibition on the number of cerebrovascular microembolic events in patients undergoing TAVI. Patients scheduled for TAVI were randomized previous to the procedure to either aspirin and ticagrelor or to aspirin and clopidogrel. Platelet inhibition was expressed in P2Y12 reaction units (PRU) and percentage of inhibition. High intensity transient signals (HITS) were assessed with transcranial Doppler (TCD). Safety outcomes were recorded according to the VARC-2 definitions. Among 90 patients randomized, 6 had an inadequate TCD signal. The total number of procedural HITS was lower in the ticagrelor group (416.5 [324.8, 484.2]) (42 patients) than in the clopidogrel group (723.5 [471.5, 875.0]) (42 patients), p <0.001. After adjusting for the duration of the procedure, diabetes, extra-cardiac arteriopathy, BMI, hypertension, aortic valve calcium content, procedural ACT, and pre-implantation balloon valvuloplasty, patients on ticagrelor had on average 256.8 (95% CI: [-335.7, -176.5]) fewer total procedural HITS than patients on clopidogrel. Platelet inhibition was greater with ticagrelor 26 [10, 74.5] PRU than with clopidogrel 207.5 (120 to 236.2) PRU, p <0.001, and correlated significantly with procedural HITS (r = 0.5, p <0.05). In conclusion, ticagrelor resulted in fewer procedural HITS, compared with clopidogrel, in patients undergoing TAVI, while achieving greater platelet inhibition.

The role of imaging in the management of renal masses.

The wide availability of cross-sectional imaging is responsible for the increased detection of small, usually asymptomatic renal masses. More than 50 % of renal cell carcinomas (RCCs) represent incidental findings on noninvasive imaging. Multimodality imaging, including conventional US, contrast-enhanced US (CEUS), CT and multiparametric MRI (mpMRI) is pivotal in diagnosing and characterizing a renal mass, but also provides information regarding its prognosis, therapeutic management, and follow-up. In this review, imaging data for renal masses that urologists need for accurate treatment planning will be discussed. The role of US, CEUS, CT and mpMRI in the detection and characterization of renal masses, RCC staging and follow-up of surgically treated or untreated localized RCC will be presented. The role of percutaneous image-guided ablation in the management of RCC will be also reviewed.

Acute Leriche Syndrome in Pancreatic Adenocarcinoma: A Case Report.

INTRODUCTION: Coexistance of pancreatic carcinoma and Leriche syndrome is an extremely rare pathological condition. Leriche syndrome is defined as occlusion of the distal aorta at the bifurcation into the common iliac arteries. CASE REPORT: We report the case of a 57-year old male patient with a locally advanced pancreatic tumor that during chemotherapy presented Leriche syndrome. Four months after the diagnosis and although the initial staging by MRI had only revealed a few atheromatic lesions of the abdominal aorta, the patient complained about claudication of the legs and hypoesthesia. Angiography with multi-detector computed tomography (MDCTA) was performed using aortography protocol and three-dimensional reconstruction of the images followed, demonstrating the relationship between pancreatic carcinoma and Leriche syndrome. CONCLUSION: Review of the literature revealed that acute abdominal thrombosis is rare in cancer patients. To our knowledge, complete occlusion of the aorta in a patient with pancreatic cancer has not been reported yet.

Impact of balloon aortic valvuloplasty on transcatheter aortic valve implantation with self-expandable valve.

BACKGROUND: Balloon aortic valvuloplasty (BAV) has been used prior to valve implantation of a self-expandable valve as part of the transcatheter aortic valve implantation (TAVI) procedure. We aimed to evaluate the impact of BAV prior to TAVI. METHODS: We retrospectively studied 203 consecutive patients who were treated either with (pre-BAV-TAVI group) or without BAV (D-TAVI group). Implantation depth (ID) was angiographically measured at non-coronary cusp (NCC) and left coronary cusp (LCC) at: the starting point (stage-1), before (stage-2), and after (stage-3) final bioprosthesis release. Paravalvular regurgitation (PVR) and 1-year clinical follow-up were recorded. RESULTS: Overall, from stage-1 to stage-3, prosthesis migrated toward the left ventricle, in both cusps and groups. At NCC a forward migration was observed from stage-1 to stage-2 in both groups (p<0.001). In the pre-BAV-TAVI group only, at NCC, an upward migration decreased the ID from stage-2 to stage-3 (p=0.022). PVR ≥grade 2, immediately after expansion was more frequently observed in pre-BAV-TAVI group (41% vs 22%, respectively; p=0.024). However, PVR was similar at discharge. Clinical parameters were comparable between the two groups. CONCLUSIONS: The use of BAV prior to TAVI may have an impact on device final position, but not on short- and long-term clinical outcome.