Subacute saphenous vein graft stent thrombosis due to unusual drug interaction: a case report

Background

Stent thrombosis is a potentially lethal complication of coronary angioplasty and responsible for 20% of all post-angioplasty myocardial infarctions. Unusual causes may be overlooked and difficult to identify.

Case summary

A 70-year-old male with history of triple aortocoronary bypass presented with acute inferolateral ST-segment elevation myocardial infarction (STEMI). Critical stenosis of the vein graft to the right coronary artery was revealed, and with the use of distal embolic protection device, successful angioplasty with stent was performed under double antiplatelet treatment with aspirin and ticagrelor. Two weeks later, he presented again at the emergency department with an acute inferolateral STEMI. Subacute stent thrombosis with complete occlusion of the stented vein graft was evident. Repeated balloon dilatations restored the flow stabilizing the patient; optical coherence tomography showed good stent expansion and apposition. Scrutinizing the patient's history, we discovered comedication with carbamazepine that is a CYP3A4 inducer and reduces ticagrelor's effect. Switching to prasugrel ensured potent antiplatelet treatment, and the patient was discharged 5 days later. The 6-month follow-up was uneventful and free of symptoms.

Discussion

Stent thrombosis has dire consequences, and the precipitating factors should always be investigated. Inadequate platelet inhibition secondary to non-compliance to therapy or resistance and suboptimal stent expansion/apposition are its main causes. Drug interactions are an underrecognized factor that may significantly alter the potency of antiplatelet drugs and also lead to stent thrombosis; thus, treatment is essential to be tailored to each patient comedication.

Fourth generation e-cigarette vaping induces transient lung inflammation and gas exchange disturbances: results from two randomized clinical trials

When heated by an electronic cigarette, propylene glycol and glycerol produce a nicotine-carrying-aerosol. This hygroscopic/hyperosmolar aerosol can deposit deep within the lung. Whether these deposits trigger local inflammation and disturb pulmonary gas exchanges is not known. The aim of this study was to assess the acute effects of high-wattage electronic cigarette vaping with or without nicotine on lung inflammation biomarkers, transcutaneous gas tensions, and pulmonary function tests in young and healthy tobacco smokers. Acute effects of vaping without nicotine on arterial blood gas tensions were also assessed in heavy smokers suspected of coronary artery disease. Using a single-blind within-subjects study design, 25 young tobacco smokers underwent three experimental sessions in random order: sham-vaping and vaping with and without nicotine at 60 W. Twenty heavy smokers were also exposed to sham-vaping (n = 10) or vaping without nicotine (n = 10) in an open-label, randomized parallel study. In the young tobacco smokers, compared with sham-vaping: 1) serum club cell protein-16 increased after vaping without nicotine (mean ± SE, −0.5 ± 0.2 vs. +1.1 ± 0.3 µg/l, P = 0.013) and vaping with nicotine (+1.2 ± 0.3 µg/l, P = 0.009); 2) transcutaneous oxygen tension decreased for 60 min after vaping without nicotine (nadir, −0.3 ± 1 vs. −15.3 ± 2.3 mmHg, P < 0.001) and for 80-min after vaping with nicotine (nadir, −19.6 ± 2.8 mmHg, P < 0.001). Compared with sham vaping, vaping without nicotine decreased arterial oxygen tension for 5 min in heavy-smoking patients (+5.4 ± 3.3 vs. −5.4 ± 1.9 mmHg, P = 0.012). Acute vaping of propylene glycol/glycerol aerosol at high wattage with or without nicotine induces airway epithelial injury and sustained decrement in transcutaneous oxygen tension in young tobacco smokers. Intense vaping conditions also transiently impair arterial oxygen tension in heavy smokers.

Drug-Eluting Resorbable Magnesium Scaffold Implantation in ST-Segment Elevation Myocardial Infarction: A Pilot Study

OBJECTIVES

To assess feasibility and short-term clinical outcomes associated with resorbable magnesium scaffold (RMS) implantation in the setting of primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI).

BACKGROUND

RMS implantation has demonstrated favorable clinical outcomes in stable coronary artery disease patients. However, to date, data are lacking in the setting of STEMI.

METHODS

This is a single-center prospective non-randomized pilot study. Patients admitted for STEMI were enrolled according to prespecified inclusion and exclusion criteria. The primary endpoint was device-oriented composite endpoint (DOCE), including cardiac death, target-vessel myocardial infarction, and target-lesion revascularization (TLR) within 30 days of the index procedure. Secondary endpoints were procedural success, any probable/definite scaffold thrombosis, and DOCE at subsequent follow-up.

RESULTS

From December 1, 2016 to October 30, 2017, a total of 18 patients were included. Follow-up data were available for 17 patients (94%). There was no primary endpoint event. Procedural success was 100%. Patients were followed for a median of 153 days (range, 59-326 days). Over that extended follow-up period, 1 case of TLR occurred 102 days after the index procedure. There was no case of definite or probable scaffold thrombosis.

CONCLUSIONS

This pilot study is the first to assess feasibility and clinical outcomes associated with RMS implantation in selected STEMI patients. The results seem reassuring, with favorable short-term clinical outcomes and absence of definite/probable scaffold thrombosis, and should prompt further research including randomized controlled trials evaluating RMS implantation in the setting of STEMI.

[Interest of laparoscopy in infertile couple with normal hysterosalpingography]

OBJECTIVES

The diagnostic laparoscopy has long been the key consideration in the export of female infertility. This place is being reconsidered, especially in the case of normal hysterosalpingogrophy (HSG), because of the advent of assisted reproductive technologies which are more efficient, and because of the improvement of medical imaging techniques which are more sensitive and specific. We wanted to clarify the place of the diagnostic laparoscopy in the balance of female infertility in normal HSG.

PATIENTS AND METHODS

It is a retrospective study on a series of 100 observations of infertile patients with a normal HSG and having a diagnostic laparoscopy in the department of Gynecology and Obstetrics at Farhat Hached hospital in Sousse (Tunisia) from 1st January 1993 to 1st March 2003.

RESULTS

The mean age was 32.3years; the mean duration of infertility was 70.47months. Laparoscopy revealed pelvic abnormalities in 45% of cases, dominated by disease tubo-adhesions (23%), endometriosis was found in 6% of cases. These anomalies are considered major in 23% of cases and minor in 22% of cases. Conducting a surgical procedure in the same operating time (adhesiolysis, tubal plastic surgery, electrocoagulation of endometriosis implants) could improve the prognosis of fertility. Only 20 patients were followed among the 45 with pelvic abnormalities, seven pregnancies have been completed (35% of cases).

DISCUSSION AND CONCLUSION

Laparoscopy has improved the prognosis for the fertility of our patients by treating abnormalities involved in infertility. It is estimated that the prognosis can be improved by selecting patients with risk factors for pelvic abnormalities.

[Cephalopagus conjoined twins: case report and review of literature]

Cephalopagus are a rare variant of conjoined twins resulting from an incomplete late division of the embryonic disk and associated with an extremely poor fetal prognosis. Here, we report a rare case of a male cepahalopagus conjoined twins diagnosed during the 23rd week of gestation. Delivery was vaginal showing twins fused from the top of the head to the umbilicus. The fused skull showed a cephalocele with agenetic brain. Esophagus, stomach and duodenum are common for the two twins. Causes, diagnosis and management of cephalopagus are discussed referring to literature.

[Impact of the mode of arrival in the emergency department for patients with a STEMI and the clinical outcomes in terms of ejection fraction and survival]

Emergency Medical Services (EMSs) play a key role in the recognition and treatment of ST-segment elevation myocardial infarction (STEMI). This study evaluates patient outcome according to his mode of arrival in the care unit dealing with acute coronary syndromes.

METHODS

Retrospective analysis of STEMI infarctions registered by the Belgian Interdisciplinary Working Group on Acute Cardiology (BIWAC) at Saint-Pierre University Hospital, Brussels (C.H.U. Saint-Pierre), between 01/01/2005 and 31/12/2006. Comparison of two groups according to their arrival in the care system: group 1: brought in following an emergency call by mobile medical team (SMUR) or normal ambulance ; group 2: arrived at the hospital by their own means and classic admission to Emergency Service.

STUDIED PARAMETERS

descriptive patient characteristics, localisation of the infarction and survival to the end of hospitalization, to six months and to one year.

RESULTS

Among 136 patients, 56.6 % arrived by EMS and 43.4 % by their own means. Patients who arrived by EMS were older (p = 0.008) and had a higher Killip score (p < 0.05). Pain-to-Angiography and Door-to-Angiography intervals were shorter in patients who arrived by EMS (222 vs 416 mins, p < 0.0001 and 62.6 vs 147 mins, p < 0.0001, respectively). There were no differences in the left ventricular ejection fraction (LVEF) and survival. However, for patients suffering an IVA attack, survival to six months and one year was better in the EMS group (88.9% vs 78.3%, p < 0.05 and 80.5 % vs 69.6 %, p = 0.05). In conclusion, dealing with STEMI infarctions is quicker by EMS admission. The infarctions admitted by this way are more serious. Wherever STEMI infarctions were localised, no improvement of LV function and survival was observed according to the mode of arrival, contrary to the subgroup with an IVA attack where survival is better at six months and one year by EMS admission.