Objectives “Clopidogrel resistance,” also defined as heightened platelet reactivity (HPR) while on clopidogrel therapy, may lead to a sub-optimal antiplatelet effect and a potential thrombotic event. There is limited literature addressing the prevalence of HPR in a large cohort of patients receiving either coronary or endovascular interventions. Methods In a large integrated healthcare system, patients with a P2Y12 reaction units (PRU) test were identified. HPR was defined as a PRU ≥ 200 during clopidogrel therapy. Vascular and coronary interventions were identified utilizing CPT codes, HPR prevalence was calculated, and Fischer’s exact test was used to determine significance. Results From an initial cohort of 2,405,957 patients (October 2014 to January 2020), we identified 3301 patients with PRU tests administered. Of these, 1789 tests had a PRU ≥ 200 (HPR overall prevalence, 54%). We then identified 1195 patients who underwent either an endovascular or coronary procedure and had a PRU measurement. This corresponded to 935 coronary and 260 endovascular interventions. In the coronary cohort, the HPR prevalence was 54% (503/935). In the vascular cohort, the HPR prevalence was 53% (137/260); there was no difference between cohorts in HPR prevalence ( p = 0.78). Conclusion “Clopidogrel resistance” or HPR was found to be present in nearly half of patients with cardiovascular disease undergoing intervention. Our data suggest HPR is more common in the cardiovascular patient population than previously appreciated. Evaluating patients for HPR is both inexpensive ($25) and rapid (< 10 min). Future randomized studies are warranted to determine whether HPR has a clinically detectable effect on revascularization outcomes.

Background Percutaneous cholecystostomy tube (PCT) drainage is an effective management strategy for acute cholecystitis in patients medically unfit for surgery. However, little is known about the fate of patients managed by PCT. We conducted this study to determine tube management outcomes for patients with acute cholecystitis managed by PCT. Methods The electronic record was queried to identify patients with acute cholecystitis managed by PCT from 2012-2020. Patients were divided into three groups for analysis: 1) ultimately managed by cholecystectomy, 2) eventual confirmation of distal flow of bile from the gallbladder and tube removal, and 3) tubes left in place without further management. Results A total of 179 patients with acute cholecystitis treated by PCT were included. Sixty-six patients never fully recovered from the medical insult associated with their diagnosis of acute cholecystitis and had their tubes left in situ. Sixty-four of these 66 patients (97%) died during follow-up. The remaining 113 patients recovered from their illness and presented to clinic for evaluation for tube removal and/or cholecystectomy. When distal biliary flow was confirmed, tube removal was favored (n = 70). When cystic duct outflow occlusion persisted, cholecystectomy was planned for patients who became acceptable surgical candidates (n = 43). For patients managed by cholecystectomy, 8 were approached open and 35 laparoscopically, with 12 of 35 (34.3%) converted to open and 23 (65.7%) completed laparoscopically. Conclusion Our study favors PCT removal for patients who recover from their acute illness when distal bile flow from the gallbladder is confirmed. We reserve cholecystectomy for patients who recover from their illness and demonstrate persistent cystic duct outflow obstruction.

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were queried for carotid stenting procedures (CAS). Emergent and bilateral procedures, patients with prior ipsilateral CAS, ICA lesions with stenosis of <50%, and hybrid transcarotid procedures were excluded. The cohort was stratified by symptomatic status. The primary outcome was the composite of perioperative neurologic events and death. Predictors of stroke/death were determined with multivariable logistic regression for symptomatic and asymptomatic patients with tandem lesions forced into the models.Results: There were 18,886 carotid arteries stented (18,441 patients); 18,077 (96%) with isolated lesions, 809 (4%) with tandem lesions. The mean age was 70.0 6 9.7 years. Symptomatic lesions were present in 58.9% of cases (isolated, 59.1% vs tandem, 52.5%; P < .001). More tandem group arteries had a prior carotid endarterectomy (38.3% vs 23.8%; P < .001). Neuroprotection was more likely to be successfully deployed with isolated lesions (94.7% vs 91.1%; P < .001). Tandem lesions had a higher perioperative stroke/death (4.7% vs 2.5%; P ¼ .007) for asymptomatic lesions, but not symptomatic lesions (5.4% vs 5.3%; P ¼ .92). Tandem lesions were independently associated with stroke/death in asymptomatic patients (odds ratio, 1.91; 95% confidence interval, 1.16-3.16; P ¼ .012) but not symptomatic patients (Table ).Conclusions: The addition of endovascular treatment of tandem CCA lesions with CAS is associated with almost double the risk of perioperative stroke/death in asymptomatic patients and should be avoided if possible. Treatment of tandem lesions is not associated with an increased risk of stroke/death for symptomatic lesions.

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