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

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

7. Risk factors for stent thrombosis

8. STRATIFICAZIONE PER RISCHI TROMBOSI/EMORRAGIA
RISCHIO EMORRAGICO
BASSO
MEDIO
ALTO
STOP ENTRAMBI
NESSUNA SOSPENSIONE
STOP 1 FARMACO
???
RISCHIO
TROMBOTICO
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or eye surgery in whom dual antiplatelet therapy could not be withdrawn as the time of surgery was within 6 months of the placement of any DES, or within one year of the placement of any DES under conditions considered to be at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

13. Global experience : 30 patients
- 8 cardiac surgery, 6 urinary tract , 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 ).

14. Patient characteristics and bleeding gastroenteric 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 68
LMCA, LAD 1,
Paclitaxel
STEMI
Hemicolotomy; cancer 62
120
No bleeding, 2U RBC pre-operatively 2
Female 78
LAD
12, everolimus
Stable angina 72
No bleeding, no transfusion 3 71
LMCA, LCx, RCA
4, paclitaxel, everolimus
NSTEACS
Cholecystectomy; recurrent cholecystitis
114 48 4 69
LAD, Lcx 8,
Pharyngotomy, cancer
111 5
NTEACS
113
312
Reoperation due to occlusion 6 80 9,
Everolimus
Endoscopic polypectomy, cancer 7 60 7,
Resection of the rectum, cancer
112
384
No bleeding, no transfusion Reoperation due to occlusion 8 65
RCA 2,
Sirolimus
Gastrectomy, hemicolotomy, cancer 9 77 4,
Sigmoid resection, cancer 98 10 73 3,
everolimus
Hemicolotomy, cancer
105 94
Major bleeding on 7th post-op day from enterocolic anastomosis. Resolved by operative coloscopy (2 clips). 6 U GRC transfused.

15. Patient characteristics and bleeding urinary tract 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
No bleeding, no transfusion 2 79
LAD
12, sirolimus
STEMI
120 3 60
LCx, RCA
3, sirolimus
Conservative nephrotomy; cancer 96 48 4 76
2, everolimus
NSTEACS
No bleeding, transfusion of 3U RBC due to proctorrhagia on 6th post-operative day; angiodysplasia 5 59
4, paclitaxel
Endoscopic bladder surgery; cancer
114
288
Minor bleeding, transfusion of 4U RBC 6 78
RCA

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