“To close or not to close?” When should vascular closure devices be used after cardiac catheterization procedures?

• Vascular closure devices (VCD) appear to be safe when compared to manual compression or surgical closure.
• VCDs’ main advantage seems to stem from lower time to hemostasis (TTH) and time to mobilization.
• In anticoagulated patients with 6‐Fr femoral sheaths, the new Celt ACT VCD, which uses a stainless‐steel permanent implant, seems to be safe and decreases TTH when compared to manual pressure.

     

Clopidogrel “Resistance”: Where are We Now?

Antiplatelet therapy with aspirin and clopidogrel in PCI patients, though effective, is still associated with thrombotic complications. These are multifactorial in origin, but partially attributable to “clopidogrel resistance.” However, how best to identify and manage “clopidogrel resistance” remains unclear. Targeting therapeutic changes specifically at those individuals with poor response to clopidogrel is likely to be a solution. A “one size fits all” approach to clopidogrel dosing is probably flawed. This review will explore (1) the definition and mechanisms of clopidogrel resistance, (2) assessment of clopidogrel resistance by (i) platelet function testing and (ii) genetic testing, (3) the management of “clopidogrel resistance,” and (4) newer antiplatelet agents, and evolving stent technology. A pubmed literature review was performed using the keywords “clopidogrel”, “resistance”, “poor response”, “adverse events”, “platelet function tests”, and “genetic tests”. In looking at new agents, keywords “prasugrel”, “cangrelor”, “ticagrelor”“Elinogrel”, and “P2Y12 receptor antagonists” were used. Third, a search was performed looking at “stent design”, “IVUS”, “bioabsorbable stents”, and “stent apposition”. Whilst new P2Y12 receptor antagonists and improved stent technology may reduce thrombotic events in the future, there is still a need for clopidogrel. There is good evidence that poor response to clopidogrel is associated with adverse outcome. Platelet function tests probably provide more clinically useful data than genetic tests, but the question of how best to identify and manage variability in response to clopidogrel demands further research.