14 Oct 10

Urgent surgery in patients with a recently implanted coronary drug-eluting stent: a phase II study of ‘bridging’ antiplatelet therapy with tirofiban during temporary withdrawal of clopidogrel

Posted in Antiplatelet therapy, Coronary artery disease, Pre-operatie evaluation at 9:55 by Laci

By S Savonitto, M D’Urbano, M Caracciolo, F Barlocco, G Mariani, M Nichelatti,

BJA 2010;104:285-291

Patients with a recently implanted coronary drug-eluting stent (DES) who need urgent surgery are at increased risk of surgical bleeding unless clopidogrel is discontinued beforehand, but clopidogrel discontinuation has been associated with a high rate of adverse events due to stent thrombosis. This pilot study tested the hypothesis that the i.v. perioperative administration of the short-acting antiplatelet agent tirofiban allows the safe withdrawal of clopidogrel without increasing the rate of surgical bleeding.

Methods
Phase II study with a Simon two-stage design.

Results
Thirty patients with a recently implanted DES [median (range) 4 (1–12) months] and high-risk characteristics for stent thrombosis underwent urgent major surgery or eye surgery. Clopidogrel was to be withdrawn 5 days before surgery, and tirofiban started 24 h later, continued until 4 h before surgery, and resumed 2 h after surgery until oral clopidogrel was resumed. The use of aspirin was decided by the surgeon. There were no cases of death, myocardial infarction, stent thrombosis, or surgical re-exploration due to bleeding during the index admission, with a risk estimate of 0–11.6% (one-tail 97.5% CI). There was one case of thrombolysis in myocardial infarction (TIMI) major and one of TIMI minor bleeding in the postoperative phase; another four patients were transfused without meeting the TIMI criteria for major or minor bleeding.

Conclusions
In patients with a recently implanted DES and high-risk characteristics for stent thrombosis needing urgent surgery, a ‘bridging strategy’ using i.v. tirofiban may allow temporary withdrawal of oral clopidogrel without increasing the risk of bleeding.

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