ABSTRACT
Overview In addition to surgical management of thrombotic disorders, in particular those involving the arterial system including Acute Coronary Syndrome (ACS), atrial fibrillation, thrombotic and ischemic stroke, and other ischemic and occlusive disorders, advanced interventional methods including stenting and molecular/cellular approaches involving genes and stem cellbased approaches are now used. Each year in the United States myocardial infarction contributes to over 600,000 deaths and an additional 800,000 deaths are attributed to this syndrome in hospital discharged patients. Thus, almost 1.5 million deaths are related to myocardial infarction and its manifestations. Percutaneous Interventions (PCI) have significantly contributed to the management of acute coronary syndrome and improved the clinical outcome in this syndrome. Similarly, interventional procedures have also been used in the management of atrial fibrillation and embolic stroke. Although the interventional methods have been extremely valuable, there are several specific pathophysiologic and pharmacologic problems, which require a continual review and assessment to optimize patient care. Coronary Interventions represent a controlled injury to the vessel wall resulting in the generation of tissue factor that initially promotes thrombogenesis at the site of injury. Regardless of the extent of this injury, both the acute and late occlusive process are often associated with PCI, necessitating pharmacological and mechanical measures to avoid occlusive events. Many of the fateful events occur in patients free of coronary artery diseases, with almost an equal number of events occuring in those with known coronary artery diseases already receiving therapy, including PCI and aggressive medical therapy with statins, antiplatelet drugs, and anticoagulants. A great number of these infarctions result from the
rupture of high-risk unstable plaque that in most cases did not impede flow before the acute events. Therefore, it is quite clear that newer approaches must be developed to understand the pathogenesis of occlusive coronary events and to develop methods for their optimal management. Risk assessment involving newer approaches based on genetic predisposition, lifestyle, and other contributing factors may be important. Other problems related to the management of vascular injury, the patency of the stents, and the role of different drugs used in the control and mediation of the thrombotic and bleeding complications observed during and after PCI require serious considerations. Interventional approaches have been in an evolutionary phase for the past two decades. Besides the proper understanding of pathogenesis of the lesions requiring interventions, post-interventional monitoring and additional control of the pathogenesis of thrombotic and fibrotic complications is equally important. Excessive bleeding with the use of newer anticoagulants, thrombotic complications with drug-coated stents and molecular and cellular abberations due to gene and stem cell approaches will require further understanding of the mechanisms involved in these processes. A firm understanding of the hemostasis and thrombosis is crucial in the optimal management of patients undergoing interventions.
