LINEE GUIDA E FLOW CHART OPERATIVA PER LA SOSPENSIONE “SICURA” DELLA TERAPIA ANTIAGGREGANTE IN PREPARAZIONE DELL’INTERVENTO

CHIRURGIA MAGGIORE

Risk of early surgery after stent implantation

Early surgery after stent implantation:High risk after discontinuation of dual antiplatelet therapy

LINEE GUIDA ESC 2009

emorragia

trombosi

VALUTAZIONE RISCHIO/BENEFICIO ED IMPATTO CLINICO

NeurochirurgiaChirurgia Oftalmica

DES su TC/IVAUltimo vaso

Risk factors for stent thrombosis

STRATIFICAZIONE PER RISCHI TROMBOSI/EMORRAGIA

BASSO MEDIO ALTO

BASSO STOP ENTRAMBI STOP ENTRAMBI

STOP ENTRAMBI

MEDIO NESSUNA SOSPENSIONE

STOP 1 FARMACO

STOP ENTRAMBI

ALTO NESSUNA SOSPENSIONE

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RISCHIOTROMBOTICO

RISCHIO EMORRAGICO

Adattata da Riddell et al, Circulation 2007; 116: e378-e382

Protocollo Ospedale Niguarda

Clopidogrel bridging protocolInclusion criteria

Consecutive candidates for urgent major (CV or non-CV) surgery or eye surgery in whom dual antiplatelet therapy could not be withdrawn as the time of surgery was within 6 months of the placement of any DES, or within one year of the placement of any DES under conditions considered to be at higher risk for stent thrombosis: •stent implantation due to an ACS,•diabetes, •renal insufficiency or •severe left ventricular dysfunction, •stents placed in LMCA, proximal LAD (or equivalent), bifurcation

- 8 cardiac surgery, 6 urinary tract , 10 gastroenteric surgery, 5 other surgery - No MACE ( death, MI, stroke )- 1 TIMI major bleeding

- 8 patients required blood transfusion (6 before surgery for anemia, 2 post-operatively for proctorrhagy ).

Global experience : 30 patients

Patient

No.

Gender Age Stented

artery

Months after

DES, type of

DES

Reason

for PCI

Type of surgery;

diagnosis

Tirofiban

infusion pre-

surgery (hrs)

Tirofiban

infusion post-

surgery (hrs)

Bleeding events*

1 Male 68 LMCA, LAD 1,

Paclitaxel

STEMI Hemicolotomy; cancer 62 120 No bleeding, 2U RBC pre-

operatively

2 Female 78 LAD 12,

everolimus

Stable

angina

Hemicolotomy; cancer 72 120 No bleeding, no transfusion

3 Male 71 LMCA, LCx, RCA 4, paclitaxel,

everolimus

NSTEACS Cholecystectomy;

recurrent cholecystitis

114 48 No bleeding, no transfusion

4 Male 69 LAD, Lcx 8,

Paclitaxel

Stable

angina

Pharyngotomy, cancer 111 0 No bleeding, no transfusion

5 Female 72 LAD 1,

Paclitaxel

NTEACS Hemicolotomy; cancer 113 312 No bleeding, no transfusion

Reoperation due to occlusion

6 Male 80 LAD 9,

Everolimus

Stable

angina

Endoscopic

polypectomy, cancer

72 0No bleeding, no transfusion

7 Male 60 LAD 7,

Everolimus

STEMI Resection of the

rectum, cancer

112 384 No bleeding, no transfusion

Reoperation due to occlusion

8 Male 65 RCA 2,

Sirolimus

NSTEACS Gastrectomy,

hemicolotomy, cancer

120 120 No bleeding, no transfusion

9 Female 77 LAD 4,

Sirolimus

NSTEACS Sigmoid resection,

cancer

113 98No bleeding, no transfusion

10 Male 73 LAD 3,

everolimus

STEMI Hemicolotomy, cancer 105 94 Major bleeding on 7th post-op day from enterocolic

anastomosis. Resolved by operative coloscopy (2 clips). 6

U GRC transfused.

Patient characteristics and bleedinggastroenteric surgery

Patient

No.

Gender Age Stented

Artery

Months

after DES,

type of

DES

Reason

for PCI

Type of surgery;

diagnosis

Tirofiban

infusion pre-

surgery (hrs)

Tirofiban

infusion post-

surgery (hrs)

Bleeding events*

1 Male 56 LMCA,

RCA

6,

sirolimus

Stable

angina

Bladder surgery;

cancer

100 0 No bleeding, no transfusion

2 Male 79 LAD 12,

sirolimus

STEMI Bladder surgery;

cancer

120 0 No bleeding, no transfusion

3 Male 60 LCx, RCA 3,

sirolimus

Stable

angina

Conservative

nephrotomy;

cancer

96 48 No bleeding, no transfusion

4 Male 76 LAD 2,

everolimus

NSTEACS Conservative

nephrotomy;

cancer

120 48 No bleeding, transfusion of

3U RBC due to

proctorrhagia on 6th post-

operative day;

angiodysplasia

5 Male 59 LAD 4,

paclitaxel

STEMI Endoscopic

bladder surgery;

cancer

114 288 Minor bleeding, transfusion of

4U RBC

6 Male 78 RCA 2,

everolimus

Stable

angina

Bladder surgery;

cancer

120 0 No bleeding, no transfusion

Patient characteristics and bleedingurinary tract surgery

Patient characteristics and bleeding: Cardiac surgery

LIMITAZIONI DEL PROTOCOLLO ‘NIGUARDA’

• Utilizzo ‘off label’ del tirofiban• Persiste rischio emorragico non trascurabile• Incertezze associazione eparina