Surgery after drug-eluting stent implantation: it’s not all doom and gloom!

Saia, Francesco

doi:10.21037/jtd.2017.03.126

Cited by 12 publications

(4 citation statements)

References 27 publications

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“…The findings support the recommendation that aspirin discontinuation in this patient population should be advocated only under circumstances where the risk of adverse outcomes caused by bleeding risk clearly outweighs that of catastrophic atherothrombotic events. These findings have been confirmed in later studies (70)(71)(72)(73)(74)(75)(76)(77)(78)150). Conversely, recently published large-scale evidence (15)(16)(17)(18)(19) shows lack of benefit of aspirin for primary prevention of cardiovascular events, but aspirin therapy is associated with increased bleeding episodes.…”

Section: Introductionsupporting

confidence: 67%

“…Therefore, overlap between chronic persistent pain and cardiovascular disease has a synergistic impact on physical and psychological health, affecting performance of social responsibilities, including work and family life. Antithrombotic therapy has a clear evidence-based foundation with a favorable risk-benefit profile for prevention and management of cardiovascular disease, including limiting the present and future burden of cardiac or cerebrovascular infarcts (4,5,(15)(16)(17)(18)(19)(55)(56)(57)(58)(67)(68)(69)(70)(71)(72)(73)(74)(75)(76)(77)(78)(79)(80)(81). Of note, a significant proportion of patients with established cerebrovascular, cardiovascular or peripheral vascular disease who are receiving antithrombotic therapy, are commonly in need of interventions including surgery and interventional pain management techniques, despite the debate regarding their safety, clinical and cost effectiveness, and indications with numerous regulations (1,(22)(23)(24)(25)(26)(27)(28)(29)(30).…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Responsible, Safe, and Effective Use of Antithrombotics and Anticoagulants in Patients Undergoing Interventional Techniques: American Society of Interventional Pain Physicians (ASIPP) Guidelines

Manchikanti

2019

Pain Phys

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Background: Interventional pain management involves diagnosis and treatment of chronic pain. This specialty utilizes minimally invasive procedures to target therapeutics to the central nervous system and the spinal column. A subset of patients encountered in interventional pain are medicated using anticoagulant or antithrombotic drugs to mitigate thrombosis risk. Since these drugs target the clotting system, bleeding risk is a consideration accompanying interventional procedures. Importantly, discontinuation of anticoagulant or antithrombotic drugs exposes underlying thrombosis risk, which can lead to significant morbidity and mortality especially in those with coronary artery or cerebrovascular disease. This review summarizes the literature and provides guidelines based on best evidence for patients receiving anti-clotting therapy during interventional pain procedures. Study Design: Best evidence synthesis. Objective: To provide a current and concise appraisal of the literature regarding an assessment of the bleeding risk during interventional techniques for patients taking anticoagulant and/or antithrombotic medications. Methods: A review of the available literature published on bleeding risk during interventional pain procedures, practice patterns and perioperative management of anticoagulant and antithrombotic therapy was conducted. Data sources included relevant literature identified through searches of EMBASE and PubMed from 1966 through August 2018 and manual searches of the bibliographies of known primary and review articles. Results: 1. There is good evidence for risk stratification by categorizing multiple interventional techniques into low-risk, moderate-risk, and high-risk. Also, their risk should be upgraded based on other risk factors. 2. There is good evidence for the risk of thromboembolic events in patients who interrupt antithrombotic therapy. 3. There is good evidence supporting discontinuation of low dose aspirin for high risk and moderate risk procedures for at least 3 days, and there is moderate evidence that these may be continued for low risk or some intermediate risk procedures.4. There is good evidence that discontinuation of anticoagulant therapy with warfarin, heparin, dabigatran (Pradaxa®), argatroban (Acova®), bivalirudin (Angiomax®), lepirudin (Refludan®), desirudin (Iprivask®), hirudin, apixaban (Eliquis®), rivaroxaban (Xarelto®), edoxaban (Savaysa®, Lixiana®), Betrixaban(Bevyxxa®), fondaparinux (Arixtra®) prior to interventional techniques with individual consideration of pharmacokinetics and pharmacodynamics of the drugs and individual risk factors increases safety. 5. There is good evidence that diagnosis of epidural hematoma is based on severe pain at the site of the injection, rapid neurological deterioration, and MRI with surgical decompression with progressive neurological dysfunction to avoid neurological sequelae. 6. There is good evidence that if thromboembolic risk is high, low molecular weight heparin bridge therapy can be instituted during cessation of the anticoagulant, and the low molecular weight heparin can be discontinued 24 hours before the pain procedure. 7. There is fair evidence that the risk of thromboembolic events is higher than that of epidural hematoma formation with the interruption of antiplatelet therapy preceding interventional techniques, though both risks are significant. 8. There is fair evidence that multiple variables including anatomic pathology with spinal stenosis and ankylosing spondylitis; high risk procedures and moderate risk procedures combined with anatomic risk factors; bleeding observed during the procedure, and multiple attempts during the procedures increase the risk for bleeding complications and epidural hematoma. 9. There is fair evidence that discontinuation of phosphodiesterase inhibitors is optional (dipyridamole [Persantine], cilostazol [Pletal]. However, there is also fair evidence to discontinue Aggrenox [dipyridamole plus aspirin]) 3 days prior to undergoing interventional techniques of moderate and high risk. 10. There is fair evidence to make shared decision making between the patient and the treating physicians with the treating physician and to consider all the appropriate risks associated with continuation or discontinuation of antithrombotic or anticoagulant therapy. 11. There is fair evidence that if thromboembolic risk is high antithrombotic therapy may be resumed 12 hours after the interventional procedure is performed. 12. There is limited evidence that discontinuation of antiplatelet therapy (clopidogrel [Plavix®], ticlopidine [Ticlid®], Ticagrelor [Brilinta®] and prasugrel [Effient®]) avoids complications of significant bleeding and epidural hematomas. 13. There is very limited evidence supporting the continuation or discontinuation of most NSAIDs, excluding aspirin, for 1 to 2 days and some 4 to 10 days, since these are utilized for pain management without cardiac or cerebral protective effect. Limitations: The continued paucity of the literature with discordant recommendations. Conclusion: Based on the survey of current literature, and published clinical guidelines, recommendations for patients presenting with ongoing antithrombotic therapy prior to interventional techniques are variable, and are based on comprehensive analysis of each patient and the risk-benefit analysis of intervention. Key words: Perioperative bleeding, bleeding risk, practice patterns, anticoagulant therapy, antithrombotic therapy, interventional techniques, safety precautions, pain

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Section: Introductionsupporting

confidence: 67%

Section: Introductionmentioning

confidence: 99%

Responsible, Safe, and Effective Use of Antithrombotics and Anticoagulants in Patients Undergoing Interventional Techniques: American Society of Interventional Pain Physicians (ASIPP) Guidelines

Manchikanti

2019

Pain Phys

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“…Many patients undergoing surgical procedures are in a hypercoagulable state and have inflammation and stress responses, blood loss, and hemodynamic derangements. 7 All of these factors can contribute to an increased thrombotic risk. Thus, multidisciplinary discussions among cardiologists, anesthesiologists, hematologists, and surgeons generally result in continuation of dual antiplatelet therapy.…”

Section: Discussionmentioning

confidence: 99%

Ileal perforation caused by a fish bone shortly after drug-eluting stent implantation for acute myocardial infarction

Zhao

et al. 2019

J Int Med Res

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During the past century, the incidence of myocardial infarction has markedly increased worldwide. Percutaneous coronary intervention with stent implantation is often considered as the first-choice treatment, especially in emergency cases. Current guidelines recommend delayed elective noncardiac surgery for such vulnerable patients. However, few suggestions are available regarding the exact treatment strategy for patients who have already undergone percutaneous coronary intervention but suddenly need emergent noncardiac surgery for an unrelated reason. We herein present a case involving a patient with acute myocardial infarction who had undergone implantation of a drug-eluting stent and developed an ileal perforation due to fish bone ingestion 3 days postoperatively. After carefully balancing the risks of stent thrombosis and uncontrollable bleeding, dual antiplatelet therapy and low-molecular-weight heparin were given with close monitoring. Emergency laparotomy and partial small bowel resection surgery were then performed, after which the patient eventually recovered. This case indicates a possible management strategy for patients with acute myocardial infarction complicated by emergency noncardiac surgery.

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“…1 Up to 15-23% of the patients with (PCI) implantation need a surgical procedure <12 months from PCI. 4 Non-cardiac surgery…”

Section: Introductionmentioning

confidence: 99%

Axillary Plexus Block for Anesthesia Management in Patients with Acute Compartment Syndrome after Primary Percutaneous Coronary Intervention (PCI) Transradial Approach: A Case Report

Renaldi,

I Made Gede Widnyana,

Otniel Adrians Labobar

2023

Bioscmed

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Background: Acute compartment syndrome is a rare complication of the percutaneous Coronary Intervention (PCI) transradial approach but it is very hand-threatening. Treatment for acute compartment syndrome is emergent fasciotomy of the affected compartments to reduce intracompartmental pressure. Axillary plexus block is an excellent choice of anesthesia technique for elbow, forearm, and hand surgery. Case presentation: An 80-year-old, 60 kg, 168 cm man was consulted to our department with a painful swelling on his right upper arm and hand that began three hours after a primary PCI procedure. Previously, the patient had a history of hypertension and diabetes mellitus. The supporting examination results were notable for anemia (Hemoglobin 7,5 g/dL), thrombocytopenia (78 x103/uL), elevated hemostasis function (International Normalized Ratio 1.43), and high blood sugar (360 mg/dL) from echocardiography results anteroseptal and lateral hypokinetic. Before we did block, the patient was given ketamine 10 mcg IV and fentanyl 25 mcg IV for sedation. Axillary plexus block, as a type of regional anesthesia under ultrasound guidance, is a reliable substitute for general anesthesia in high-risk patients, and we do it with a dose of 20 ml of solution (50 mg (10 ml) isobaric bupivacaine 0.5% + 200 mg lidocaine 2% diluted with 20 ml normal saline). During the surgery, the patient was hemodynamically stable. After the operation, the patient was readmitted to the intensive cardiac care unit (ICCU). Conclusion: Axillary plexus block can be an alternative to general anesthesia in patients who will undergo fasciotomy surgery after percutaneous coronary intervention transradial approach with stable hemodynamics during surgery and well-controlled pain after the surgery.

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Surgery after drug-eluting stent implantation: it’s not all doom and gloom!

Cited by 12 publications

References 27 publications

Responsible, Safe, and Effective Use of Antithrombotics and Anticoagulants in Patients Undergoing Interventional Techniques: American Society of Interventional Pain Physicians (ASIPP) Guidelines

Responsible, Safe, and Effective Use of Antithrombotics and Anticoagulants in Patients Undergoing Interventional Techniques: American Society of Interventional Pain Physicians (ASIPP) Guidelines

Ileal perforation caused by a fish bone shortly after drug-eluting stent implantation for acute myocardial infarction

Axillary Plexus Block for Anesthesia Management in Patients with Acute Compartment Syndrome after Primary Percutaneous Coronary Intervention (PCI) Transradial Approach: A Case Report

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