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LINEE GUIDA E FLOW CHART OPERATIVA PER LA SOSPENSIONE SICURA DELLA TERAPIA ANTIAGGREGANTE IN PREPARAZIONE DELLINTERVENTO CHIRURGIA MAGGIORE.

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Presentation on theme: "LINEE GUIDA E FLOW CHART OPERATIVA PER LA SOSPENSIONE SICURA DELLA TERAPIA ANTIAGGREGANTE IN PREPARAZIONE DELLINTERVENTO CHIRURGIA MAGGIORE."— Presentation transcript:

1 LINEE GUIDA E FLOW CHART OPERATIVA PER LA SOSPENSIONE SICURA DELLA TERAPIA ANTIAGGREGANTE IN PREPARAZIONE DELLINTERVENTO CHIRURGIA MAGGIORE

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3 Risk of early surgery after stent implantation

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

5 LINEE GUIDA ESC 2009

6 emorragia trombosi VALUTAZIONE RISCHIO/BENEFICIO ED IMPATTO CLINICO Neurochirurgia Chirurgia Oftalmica DES su TC/IVA Ultimo vaso

7 Risk factors for stent thrombosis

8 STRATIFICAZIONE PER RISCHI TROMBOSI/EMORRAGIA BASSOMEDIOALTO BASSOSTOP ENTRAMBI MEDIONESSUNA SOSPENSIONE STOP 1 FARMACO STOP ENTRAMBI ALTONESSUNA SOSPENSIONE ??? RISCHIO TROMBOTICO RISCHIO EMORRAGICO Adattata da Riddell et al, Circulation 2007; 116: e378-e382

9 Protocollo Ospedale Niguarda

10 Clopidogrel bridging protocol Inclusion 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candidates for urgent major (CV or non-CV) surgery or eye surgery in whom dual antiplatelet therapy could not be withdrawn as the time of surgery was within 6 months of the placement of any DES, or within one year of the placement of any DES under conditions considered to be at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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13 - 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

14 Patient No. GenderAge 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* 1Male68LMCA, LAD 1, Paclitaxel STEMIHemicolotomy; cancer62120 No bleeding, 2U RBC pre- operatively 2Female78LAD 12, everolimus Stable angina Hemicolotomy; cancer72120No bleeding, no transfusion 3Male71LMCA, LCx, RCA 4, paclitaxel, everolimus NSTEACS Cholecystectomy; recurrent cholecystitis 11448No bleeding, no transfusion 4Male69LAD, Lcx 8, Paclitaxel Stable angina Pharyngotomy, cancer1110No bleeding, no transfusion 5Female72LAD 1, Paclitaxel NTEACSHemicolotomy; cancer No bleeding, no transfusion Reoperation due to occlusion 6Male80LAD 9, Everolimus Stable angina Endoscopic polypectomy, cancer 720 No bleeding, no transfusion 7Male60LAD 7, Everolimus STEMI Resection of the rectum, cancer No bleeding, no transfusion Reoperation due to occlusion 8Male65RCA 2, Sirolimus NSTEACS Gastrectomy, hemicolotomy, cancer 120 No bleeding, no transfusion 9Female77LAD 4, Sirolimus NSTEACS Sigmoid resection, cancer No bleeding, no transfusion 10Male73LAD3, everolimus STEMIHemicolotomy, cancer10594 Major bleeding on 7 th post-op day from enterocolic anastomosis. Resolved by operative coloscopy (2 clips). 6 U GRC transfused. Patient characteristics and bleeding gastroenteric surgery

15 Patient No. GenderAge 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* 1Male56 LMCA, RCA 6, sirolimus Stable angina Bladder surgery; cancer 1000No bleeding, no transfusion 2Male79LAD 12, sirolimus STEMI Bladder surgery; cancer 1200No bleeding, no transfusion 3Male60LCx, RCA 3, sirolimus Stable angina Conservative nephrotomy; cancer 9648No bleeding, no transfusion 4Male76LAD 2, everolimus NSTEACS Conservative nephrotomy; cancer No bleeding, transfusion of 3U RBC due to proctorrhagia on 6 th post- operative day; angiodysplasia 5Male59LAD 4, paclitaxel STEMI Endoscopic bladder surgery; cancer Minor bleeding, transfusion of 4U RBC 6Male78RCA2, everolimus Stable angina Bladder surgery; cancer 1200No bleeding, no transfusion Patient characteristics and bleeding urinary tract surgery

16 Patient characteristics and bleeding: Cardiac surgery

17 LIMITAZIONI DEL PROTOCOLLO NIGUARDA Utilizzo off label del tirofiban Persiste rischio emorragico non trascurabile Incertezze associazione eparina

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