Purpose. The primary objective was to compare primary and secondary patency, number of percutaneous transluminal angioplasty (PTA) interventions and cost-effectiveness among PTA, deployment of a stent, or a stent graft in the treatment of failing arteriovenous dialysis grafts. The secondary objective was to compare the residual diameter at the site of dialysis shunt stenosis using sonography and digital subtraction angiography (DSA). Methods. Sixty patients were randomly assigned to either PTA, placement of a stent or stent graft. Follow-up angiography was scheduled at 3, 6, and 12 months or when requested by the physician. Residual diameter of a dialysis shunt stenosis was measured in 20 patients with significant stenosis by ultrasonography and on an angiogram from DSA. Results. During a median follow-up of 22.4 months patients with PTA, stent, or stent graft required 3.1±1.7, 2.5±1.7, or 1.7±2.1 (P=0.031) secondary PTA interventions. The primary patency rates were 0%, 18%, and 65% at 12 months and 0%, 18%, and 37% at 24 months in the PTA, stent, and stent graft group respectively (P<0.0001). The cost of the procedures was €7,900±€3,300 in PTA group, €8,500±€4,500 in stent group, and €7,500±€6,200 in stent graft group (P=0.45). The mean residual diameter measured by ultrasonography and DSA was...

Introduction: Bivalirudin and heparin are the two most commonly used anticoagulants used during Percutaneous Coronary Intervention (PCI). The results of Randomized Controlled Trials (RCTs) comparing bivalirudin versus heparin monotherapy in the era of radial access are controversial, questioning the positive impact of bivalirudin on bleeding. The purpose of this systematic review is to summarize the results of RCTs comparing the efficacy and safety of bivalirudin versus heparin with or without Glycoprotein IIb/IIIa Inhibitors (GPI). Methods: This systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses PRISMA statements for reporting systematic reviews. We searched the National Library of Medicine PubMed, Clinicaltrial.gov and the Cochrane Central Register of Controlled Trials to include clinical studies comparing bivalirudin with heparin in patients undergoing PCI. Sixteen studies met inclusion criteria and were reviewed for the summary. Findings: Several RCTs and meta-analyses have demonstrated the superiority of bivalirudin over heparin plus routine GPI use in terms of preventing bleeding complications but at the expense of increased risk of ischemic complications such as stent thrombosis. The hypothesis of post-PCI bivalirudin infusion to mitigate the risk of acute stent thrombosis has been tested in various RCTs with conflicting results. In comparison, heparin offers the advantage of having a reversible agent, of lower cost and reduced incidence of ischemic complications. Conclusion: Bivalirudin demonstrates its superiority over heparin plus GPI with better clinical outcomes in terms of less bleeding complications, thus making it as anticoagulation of choice particularly in patients at high risk of bleeding. Further studies are warranted for head to head comparison of bivalirudin to heparin monotherapy to establish an optimal heparin dosing regimen and post-PCI bivalirudin infusion to affirm its beneficial effect in reducing acute stent thrombosis.

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The purpose of this work was to analyze the biomechanics of degeneration, damage, and failure in biological soft tissues both experimentally and computationally to provide insight into tendon or ligament tearing, tendo-achilles lengthening and lumbar spine dysfunction. For soft tissue tearing, experimental studies for calculating fracture toughness were performed and determined that tendons and ligaments are able to completely resist tear propagation. For tendo-achilles lengthening, a damage model was developed to mimic the behavior of the lengthening that occurs as a result of the percutaneous triple hemisection technique. The model provided insight for predicting the amount of lengthening that occurs during the procedure. For lumbar spine dysfunction, a finite element model was validated against experimental testing and simulated using boundary conditions representing physiological loading. The model was able to predict how biomechanical changes can lead to pain and how the prevalence of Schmorl's nodes can be predicted. For each of the situations, the best verification and validation methods were selected and are presented throughout the research to demonstrate the predictive capabilities and limitations of the work. Results of these studies are presented along with how those results influence the clinical endeavors associated with the degeneration, damage and failure of soft tissues.

Cangrelor is a relatively new antiplatelet drug that has been approved for use as an adjunct therapy to percutaneous coronary intervention (PCI) to decrease peri-procedural myocardial infarction (MI), coronary revascularization, and stent thrombosis. Cangrelor is an adenosine triphosphate analogue with a pharmacokinetic mechanism based on a reversible, dose-dependent inhibition adenosine diphosphate (ADP)-induced platelet aggregation. This drug has lately been in the spotlight as a possible bridge therapy for anti-platelet medication prior to cardiac and non-cardiac surgeries. Platelet function is usually restored within sixty minutes of cessation of therapy, thereby decreasing the risk of bleeding while providing adequate pre-procedural coverage to reduce ischemic events. This manuscript reviews the literature on cangrelor and summarizes its role as a peri-procedural bridge.

The P2Y inhibitor, ticagrelor, has been shown to prevent thrombotic events and hence, improve morbidity and mortality in patients with acute coronary syndrome following coronary artery stent placement. Despite many clinical benefits, ticagrelor has been associated with several adverse effects, including dyspnea, easy bruising, and gastrointestinal bleeding. We report the case of a 67-year-old patient with an acute coronary artery syndrome requiring percutaneous coronary artery intervention with stenting who developed ticagrelor-induced diarrhea. The patient's ticagrelor medication was replaced with clopidogrel, and his diarrhea completely resolved within one week with no complications observed at his one-month follow-up visit. Clinicians should be aware of this adverse effect of ticagrelor so as to guide them toward possible underlying etiologies and appropriate workup of chronic diarrhea.

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