Perioperative Management of a Patient with Recently Placed Drug-Eluting Stents Requiring Urgent Spinal Surgery

Roth, Eira S.; Purnell, Chad A.; Shabalov, Olga; Moguillansky, Diego; Hernandez, Caridad; Elnicki, Michael

doi:10.1007/s11606-012-1995-7

Cited by 7 publications

(9 citation statements)

References 22 publications

(55 reference statements)

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“…The American College of Cardiology, American Heart Association, and European Society of Cardiology have relatively congruent guidelines regarding the necessity of DAPT for patients with acute coronary syndrome who have undergone PCI with the placement of DES. [ 4 , 7 , 9 , 10 ] However, the duration of treatment remains controversial. Most current guidelines require 6–12 months of DAPT with aspirin and clopidogrel after PCI revascularization, with continuation of aspirin recommended indefinitely [ Table 1 ].…”

Section: Resultsmentioning

confidence: 99%

“…[ 10 ] Notably, the highest risk for stent thrombosis is within the first 6 weeks after stent placement. [ 9 ]…”

Section: Resultsmentioning

confidence: 99%

“…perioperative spinal hemorrhage resulting in severe disability or even death) versus stopping (i.e., acute stent thrombosis or even death) DAPT must be carefully weighed. [ 9 ]…”

Section: Introductionmentioning

confidence: 99%

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Perioperative dual antiplatelet therapy for patients undergoing spine surgery soon after drug eluting stent placement

Peeters

Nagasawa

Gaonkar

et al. 2021

Surgical Neurology International

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Background: Performing emergent spinal surgery within 6 months of percutaneous placement of drug-eluting coronary stent (DES) is complex. The risks of spinal bleeding in a “closed space” must be compared with the risks of stent thrombosis or major cardiac event from dual antiplatelet therapy (DAPT) interruption. Methods: Eighty relevant English language papers published in PubMed were reviewed in detail. Results: Variables considered regarding surgery in patients on DAPT for DES included: (1) surgical indications, (2) percutaneous cardiac intervention (PCI) type (balloon angioplasty vs. stenting), (3) stent type (drug-eluting vs. balloon mechanical stent), and (4) PCI to noncardiac surgery interval. The highest complication rate was observed within 6 weeks of stent placement, this corresponds to the endothelialization phase. Few studies document how to manage patients with critical spinal disease warranting operative intervention within 6 months of their PCI for DES placement. Conclusion: The treatment of patients requiring urgent or emergent spinal surgery within 6 months of undergoing a PCI for DES placement is challenging. As early interruption of DAPT may have catastrophic consequences, we hereby proposed a novel protocol involving stopping clopidogrel 5 days before and aspirin 3 days before spinal surgery, and bridging the interval with a reversible P2Y12 inhibitor until surgery. Moreover, postoperatively, aspirin could be started on postoperative day 1 and clopidogrel on day 2. Nevertheless, this treatment strategy may not be appropriate for all patients, and multidisciplinary approval of perioperative antiplatelet therapy management protocols is essential.

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Section: Resultsmentioning

confidence: 99%

“…[ 10 ] Notably, the highest risk for stent thrombosis is within the first 6 weeks after stent placement. [ 9 ]…”

Section: Resultsmentioning

confidence: 99%

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Perioperative dual antiplatelet therapy for patients undergoing spine surgery soon after drug eluting stent placement

Peeters

Nagasawa

Gaonkar

et al. 2021

Surgical Neurology International

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“…If emergency surgery is deemed necessary, yet the patient presents in the first 6 weeks, bridging of anti-platelet therapy with perioperative infusion of the glycoprotein IIb/IIIa inhibitor, eptifibatide, is an option. 15 The newer direct factor Xa inhibitors such as rivaroxiban are not currently used, and evidence is lacking on their duration of anti-coagulant effect when stopped; the general consensus is that they should be regarded as presenting a similar bleeding risk as clopidogrel, and need to be bridged if discontinued. In the event of a patient requiring emergency surgery while taking rivaroxiban for prevention of intra-cranial stent thrombosis, expert haematological advice should be sought.…”

Section: Specific Anaesthetic Considerationsmentioning

confidence: 99%

Anaesthetic considerations for patients with neurosurgical implants

Whitney

Sturgess

2016

BJA Education

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• Survival rates for patients with neurosurgical pathology are improving, resulting in more of these patients presenting for incidental surgery. The non-specialist can safely anaesthetize neurosurgical patients by adhering to general neurophysiological principles. • Cerebrospinal fluid diversion devices (shunts) used to treat hydrocephalus are not only ventriculoperitoneal, the distal end may be placed into the intrapleural space or the right atrium. The proximal end can also arise from the lumbar spine.

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“…Roth et al (25) described a case of a patient who required an L4-L5 discectomy and decompression of the L4-L5 nerve root 3 months following placement of 2 drug-eluting stents. This patient had been maintained on aspirin and clopidogrel.…”

Section: Case Reportmentioning

confidence: 99%

Use of Eptifibatide as a Bridge Antiplatelet Agent for Intrathecal Drug Delivery System Placement

Sisk

Palma²,

Cooper³

et al. 2012

Pain Phys

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Use of antiplatelet agents is becoming increasingly common, and their management may require new strategies if neuroaxial techniques are to be employed in patients who will not tolerate discontinuation of antiplatelet therapy. The patient was a 46-year-old man with a past medical history significant for coronary artery disease and who had undergone 14 stents. He developed stent thrombosis (ST) while on clopidogrel. Following the ST, he was subsequently placed on prasugrel. While on prasugrel, the patient presented for an intrathecal drug delivery system (IDDS) trial and placement due to severe peripheral neuropathy unresponsive to several conservative medical treatments. He had previously undergone an unsuccessful spinal cord stimulator trial and received no pain relief. In consultation with his outside cardiologist, the patient received permission to hold his prasugrel for 7 days prior to his intrathecal pump trial. During the trial period’s inpatient hospitalization, the patient developed chest pain. In consultation with the cardiology service in our institution, it was decided antiplatelet therapy should be re-instituted. The patient was bridged to his IDDS placement after the trial with intravenous eptifibatide. The eptifibatide drip was administered 6 hours prior to the IDDS implant. Functional platelet count was checked one hour before the IDDS was placed and the pump was placed without incident. The eptifibatide drip was reinstituted one hour after the IDDS implantation. The patient was observed for 24 hours on the eptifibatide drip, transitioned to his home dose of prasugrel, and discharged home. At outpatient follow-up one week later, the patient demonstrated no neurologic or hemorrhagic complications and was satisfied with the pain control provided by the IDDS. Prasugrel is an irreversible platelet inhibitor, which prevents ADP-induced platelet aggregation by binding the P2Y12 receptor. Patients taking prasugrel will have deficient platelet activity until new platelets have been produced, a span of approximately 7 days. Eptifibatide is an intravenous glycoprotein IIb/IIIa inhibitor with a short half-life of 2½ hours. Inhibition of glycoprotein IIb/IIIa prevents platelet activation and aggregation. The drug effect ceases once it is discontinued and restoration of platelet function is not dependent upon new platelet production. Patients requiring antiplatelet therapy in need of neuroaxial pain management procedures present challenging problems to pain management physicians. Current guidelines from the American Society of Regional Anesthesia have not identified any bridging agent suitable for patients who may not tolerate prolonged withdrawal from their antiplatelet therapy. In this case, eptifibatide was successfully utilized to bridge a patient whose comorbid conditions necessitated continuous antiplatelet therapy without the prolonged washout common to irreversible antiplatelet agents. Key words: Intrathecal drug delivery system, anticoagulation, pain, eptifibatide, antiplatelet agents.

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Perioperative Management of a Patient with Recently Placed Drug-Eluting Stents Requiring Urgent Spinal Surgery

Cited by 7 publications

References 22 publications

Perioperative dual antiplatelet therapy for patients undergoing spine surgery soon after drug eluting stent placement

Perioperative dual antiplatelet therapy for patients undergoing spine surgery soon after drug eluting stent placement

Anaesthetic considerations for patients with neurosurgical implants

Use of Eptifibatide as a Bridge Antiplatelet Agent for Intrathecal Drug Delivery System Placement

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