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

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

Risk factors for stent thrombosis

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

Protocollo Ospedale Niguarda

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candidates for urgent major (CV or non-CV) surgery or eye surgery in whom dual antiplatelet therapy could not be withdrawn as the time of surgery was within 6 months of the placement of any DES, or within one year of the placement of any DES under conditions considered to be at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

Global experience : 30 patients - 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 ).

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.

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

Patient characteristics and bleeding: Cardiac surgery

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