linee guida e flow chart operativa per la sospensione sicura della terapia antiaggregante in...
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LINEE GUIDA E FLOW CHART OPERATIVA PER LA SOSPENSIONE “SICURA” DELLA TERAPIA ANTIAGGREGANTE IN PREPARAZIONE DELL’INTERVENTO
CHIRURGIA MAGGIORE
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Risk of early surgery after stent implantation
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Early surgery after stent implantation:High risk after discontinuation of dual antiplatelet therapy
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LINEE GUIDA ESC 2009
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emorragia
trombosi
VALUTAZIONE RISCHIO/BENEFICIO ED IMPATTO CLINICO
NeurochirurgiaChirurgia Oftalmica
DES su TC/IVAUltimo vaso
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Risk factors for stent thrombosis
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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
??? ???
RISCHIOTROMBOTICO
RISCHIO EMORRAGICO
Adattata da Riddell et al, Circulation 2007; 116: e378-e382
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Protocollo Ospedale Niguarda
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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candidates for urgent major (CV or non-CV) surgery or eye surgery in whom dual antiplatelet therapy could not be withdrawn as the time of surgery was within 6 months of the placement of any DES, or within one year of the placement of any DES under conditions considered to be at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
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- 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
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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
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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
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Patient characteristics and bleeding: Cardiac surgery
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LIMITAZIONI DEL PROTOCOLLO ‘NIGUARDA’
• Utilizzo ‘off label’ del tirofiban• Persiste rischio emorragico non trascurabile• Incertezze associazione eparina
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