We carried out a prospective evaluation of a new vasodilator-stimulated phosphoprotein (VASP) phosphorylation assay in order to detect patients with high-risk coronary subacute stent thrombosis (SAT) despite thienopyridine regimen. Twenty healthy donors (group 1) without any medication were compared to 16 stented patients (group 2) treated by ticlopidin or clopidogrel initiated 2 days before stenting and aspirin (250 mg/day). No difference in platelet reactivity was noted between group 1 and group 2 treated only with aspirin (72.00% +/- 4.17% vs. 69.73% +/- 5.62%, respectively; P = NS). Significant differences were found between patients of group 2 treated with aspirin alone (69.73% +/- 5.62%), after 2.0 days (60.14% +/- 9.60%; P < 0.05), and after 4.8 +/- 1.3 days (48.37% +/- 11.19%; P < 0.05) with thienopyridine-aspirin. Among 1,684 consecutive stented patients, 16 patients who presented an SAT (group 3) were compared with 30 other stented patients free of SAT (group 4). We found a significant difference between group 3 (63.28% +/- 9.56%) and group 4 (39.80% +/- 10.9%; P < 0.0001). VASP phosphorylation analysis may be useful for the detection of coronary SAT.

Stenting of unprotected LMCA stenosis provided excellent immediate results, particularly in good CABG candidates. Medium-term results were good, with a restenosis rate of 23%, similar to that seen after stenting at other coronary sites. Stenting deserves to be considered a safe and effective alternative to CABG in institutions performing large numbers of PTCAs.

Subacute thrombosis of coronary stents may occur up to the end of the first month after their implantation and remains the major problem associated with the technique. A cohort of 238 patients with placement of one or more stents in 244 arteries was monitored for this period. All patients were given 500 mg/day of ticlopidine (started 3 days before) and a push dose of 10,000 IU of heparin during the procedure, then 1,000-1,500 IU/hr for 20 hr. Following removal of the arterial introducer, they were kept on subcutaneous heparin for 1 week and ticlopidine (500 mg/day) for 3-6 months. Nine patients (3.8%) showed evidence of thrombosis at 7 days. The overall thrombosis rate at 30 days was 4.2% (3.5% for elective stents, as compared with 7.9% associated with occlusive dissections). Emergency treatment by further angioplasty (8 cases) and intracoronary thrombolysis (5 cases) was undertaken. Complications were as follows: 5 deaths (2%), 3 MI (1.2%), 2 non-Q MI (1.7%). Three predictive factors for subacute thrombosis were identified: age < 70 (p = 0.00006), unstable angina (p = 0.006) and arterial diameter less than 3 mm (p = 0.043). The peripheral vascular complication rate was 4.6%. This study suggests that preventive treatment with ticlopidine appears to reduce the incidence of subacute thrombosis of stents in patients > 70 years of age. Furthermore, the combination of ticlopidine and heparin facilitates laboratory monitoring after stenting. Stenting is thought to represent definitive treatment in situations where placement for occlusive dissection is the indication.

Methods : in this prospective study, real time B Mode ultrasound imaging (USI) was compared to bilateral ascending contrast venography, double blindly, in 430 patients suspected of deep vein thrombosis (DVT) or pulmonary embolism.A complete scan of the venous system from the inferior vena cava to the calf veins, was performed with a high resolution duplex system (DIASONICS DRF 400) and coupled systematically with a C.W. Doppler examination. The results obtained by USI were thus compared to the venograms performed on a total of 854 legs.Results : there are corresponding results in 95% of the legs (808/854). If we consider venography as the standard of reference, the sensitivity of USI is 98% (325/333) and the specificity 94% (483/514). Isolated calf vein thrombosis are detected in 91% (84/92) of the legs and proximal DVT in 100% (241/241) in this series whatever the topography and the extension of the thrombosis and whatever the degree of the obstruction of the vein.Discrepancies found in 46 legs are related to :- 8 DVT located in the calf (6 in the presumed healthy leg) diagnosed only by venography.- 27 DVT (18 distal, 9 femoral or iliac) detected only by USI- 9 doubtful examinations with USI not confirmed by venography- 2 doubtful venograms with negative USI test.Comments : Calf vein thrombosis especially located in the soleal sinuses and the gastrocnemius with in most cases the direct image of the thrombus are more often detected by USI provided that the technique and the equipment are appropriate.The absence of visualisation of venous segments with venography is not specific of venous thrombosis. These veins non affected by the thrombosis are not filled by the contrast medium when located above in occluded ilio-femoral or ilio-caval junction or when they are the site of extrinsic compression. The direct image of the vein and the surrounding structures obtained with USI enhances the diagnostic sensitivity and specificity and provides precision of the exact extension of the thrombosis.Due to these differences, can venography still be considered as the standard of reference in the diagnosis of DVT and their precise localisation ?

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