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IV CONVENTION UTIC LOMBARDE 8-9 Aprile 2011 Gestione del rischio emorragico nella chirurgia non cardiaca maggiore Maria Rosa Conte Ospedale Mauriziano.

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Presentazione sul tema: "IV CONVENTION UTIC LOMBARDE 8-9 Aprile 2011 Gestione del rischio emorragico nella chirurgia non cardiaca maggiore Maria Rosa Conte Ospedale Mauriziano."— Transcript della presentazione:

1 IV CONVENTION UTIC LOMBARDE 8-9 Aprile 2011 Gestione del rischio emorragico nella chirurgia non cardiaca maggiore Maria Rosa Conte Ospedale Mauriziano -Torino

2 Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA) Change in numbers of discharges for surgical procedures by age for the time periods 1994/95 and 2004/05 as reported from the 2005 US National Hospital Discharge Survey (non-federal short-stayhospitals) Age (years) Number of procedures(in thousands) % change 1994/ /05 18– – – and over and over þ þ10.7

3 Impact of the ageing population Within the next 20 years, the acceleration in ageing of the population will have a major impact on perioperative patient management. It is estimated that elderly people require surgery four times more often than the rest of the population. Although exact data regarding the number of patients undergoing surgery in Europe are lacking, it is estimated that this number will increase by 25% by 2020, and for the same time period the elderly population will increase by.50%. The total number of surgical procedures will increase even faster because of the rising frequency of interventions with age.

4 Austrian Vicenzi MN BJA 2006 Incidence of surgery within 1 year after coronary stenting Cleveland Anwaruddin S JACC Intv % 5.0% 8.6% New Zealand To ACY Circ CV Intv 2009 Noncardiac Cardiac (20%) + Noncardiac Noncardiac 4.4% Scottish Cruden N Circ CV Int 2010 Noncardiac 4.4% major EVENT REGISTRY Berger PB JACC Intv 2010 Noncardiac 2.0% minor

5 Austrian N=2000 Scottish N=1,953 Cleveland N=12, Cardiovascular death Myocardial Infarction CNR-OD 1 study Events per year (%) 1083 pts with stable CAD followed for months, pre-PCI era Brunelli C. Eur Heart J Incidence of surgery first year after stent (%) In patients with stable CAD, Probability of surgery higher than probability of D+MI New Zealand Vicenzi MN. BJA 2006; Anwaruddin S. JACC Intv 2009 Cruden N. Circ CV Int 2010; To ACY. Circ CV Interv 2009


7 Patients caratheristics

8 11150 patients (age, years;30% women) who underwent PCI from 1996 to 2001 (New Zealand), 5-year follow-up: 26% of the population underwent at least 1 noncardiac surgical procedure (23% orthopedic, 20% abdominal, 12% urologic, 10% vascular, 35% others) Circ Cardiovasc Intervent. 2009;2:


10 The main clinical predictors of noncardiac surgery were advanced age, previous noncardiac surgery, osteoarthritis, and peripheral vascular disease. Noncardiac surgery is required frequently after PCI, whereas bleeding is less common. Before implanting a drug- eluting or bare-metal stent, individual patient risk stratification by the interventional cardiologist should include assessment of whether there is an increased likelihood of needing noncardiac surgery or developing bleeding.

11 Clinical presentation at the time of PCI

12 Patients undergoing noncardiac surgery after recent coronary stent implantation are at increased risk of perioperative myocardial ischemia, myocardial infarction, and death, particularly after an acute coronary syndrome. For at least 2 years after percutaneous coronary intervention, cardiac outcomes after noncardiac surgery are similar for both drug-eluting and bare-metal stents. Perioperative death and ischemic cardiac events occurred more frequently when surgery was in patients revascularized after an acute coronary syndrome (65% versus 32% - elective indication - ; P=0.037). (acute coronary syndrome [triangles] vs stable coronary artery disease [diamonds])

13 % of Subjects 2.31% DAYS Clopidogrel-treated patients 2.41% DAYS Definite/Probable ST: DES Only (N=5743) Definite/Probable ST: BMS Only (N=6461) Wiviott SD. Lancet 2008;371:1353 Time course and incidence of ST after a NSTEACS Does not differ between BMS and DES Clopidogrel-treated patients


15 Scottish Coronary Revascularisation Register From April 2003 and March 2007,1953 post-PCI patients underwent noncardiac surgery. Of these, 570 (29%) were treated with at least 1 drug-eluting stent and 1383 (71%) with bare-metal stents only. Circ Cardiovasc Interv. 2010;3: )


17 2009 ESC Guidelines on perioperative evaluation for noncardiac surgery Timing of noncardiac surgery in cardiac-stable/ asymptomatic patients with prior PCI

18 Guidelines for pre-operative cardiacmanagement in non-c Recommendations on timing of non-cardiac surgery in cardiac-stable/asymptomatic patients with prior revascularization Recommendations Class Level It is recommended that patients with previous CABG in the last 5 years be sent I C for non-cardiac surgery without further delay It is recommended that non-cardiac surgery be performed in patients with recent bare I B metal stent implantation after a minimum 6 weeks and optimally 3 months following the intervention It is recommended that non-cardiac surgery be performed in patients with recent I B drug-eluting stent implantation no sooner than 12 months following the intervention Consideration should be given to postponing non-cardiac surgery in patients with recent II a B balloon angioplasty until at least 2 weeks following the intervention


20 Class I Class IIb

21 Occurrence of early and late angiographically- documented stent thrombosis in the Rotterdam and Bern registries Daemen J, Lancet 2007;369:667 Independent predictors HR 95%CI ACS at presentation Diabetes D 3y 0.6% per year

22 Predictors of stent thrombosis the dutch registry: 437 out of 21,009 pts (2.1%) Van Werkum JW. JACC 2009;53:1399

23 Schulz S. Eur Heart J 2009;30:2714 Clopidogrel discontinuation and incidence of stent thrombosis after PCI in the ISAR studies Cumulative incidence of stent thrombosis in patients who continued (black) and those who discontinued clopidogrel (red). Patients switched from one group to the other as soon as they stopped taking clopidogrel.

24 Clinical outcome of stent thrombosis At 30-day and 180-day follow-up Airoldi F. Circulation 2007;116:745-54

25 NCS after percutaneous coronary intervention Stent Thrombosis risk Timing dellimpianto Stent SCA o coronaropatia stabile Tipo di STENT Diabete Lunghezza dello Stent Biforcazioni / lesioni ostiali… BLEEDING RISK Female sex Diabetes, Chronic renal impairment bleeding…… SURGICAL RISK Ch aortica e vascolare maggiore BLEEDING SURGICAL RISK intracranial spinal Extraocular TURP

26 RISCHIO EMORRAGICO Cataratta Trabeculectomia GlaucomaBasso Chirurgia complessa su retina Chirurgia complessa su palpebra Chirurgia complessa su ghiandole lacrimali Chirurgia complessa a livello orbitario con necessità di anestesia retro bulbareIntermedioIntermedioIntermedioAlto RISCHIO EMORRAGICO CHIRURGIA OCULARE Ickx et al. Can J Anesth 2006; 53: 6; S Thachil J. et al. British Journal of Surgery 2008; 95: 1437–1448.

27 RISCHIO EMORRAGICO CistoscopiaBasso Litotrissia Biopsia prostatica Biopsia renaleIntermedioAltoAlto RISCHIO EMORRAGICO PROCEDURE UROLOGICHE Ickx et al. Can J Anesth 2006; 53: 6; S Thachil J. et al. British Journal of Surgery 2008; 95: 1437–1448.

28 Recommendation/statement on surgical risk estimate Recommendation/statement Class Level Laparoscopic procedures demonstrate a cardiac stress similar to open procedures and it is I A recommended that patients be screened prior to intervention accordingly

29 RISCHIO EMORRAGICO del tratto gastrointestinale superiore del tratto gastrointestinale inferiore ERCP senza sfinterectomia Inserzione di stent biliare senza sfinterectomia Endosonografia senza incannulazione Enteroscopia push dellintestino tenue Capsula endoscopica con o senza biopsiaBasso<1% Polipectomia Coagulazione laser Sfinterectomia endoscopica Dilatazione pneumatica Stenting esofageo Posizionamento di PEG Trattamento di varici ERCP con sfinterectomia Resezione della mucosa o dissezione sub mucosa per via endoscopica Endoscopia ad ultrasuoni con ago aspiratoAlto1% RISCHIO EMORRAGICO PROCEDURE ENDOSCOPICHE GASTROINTESTINALI (GI) Ickx et al. Can J Anesth 2006; 53: 6; S Thachil J. et al. British Journal of Surgery 2008; 95: 1437–1448. Kwok A. et al. Am J Gastroenterol online pubblication, 11 August 2009; doi: /ajg

30 How to manage post-stent DAT & NCS?

31 British Journal of Anaesthesia 105 (S1): i3–i15 (2010) Relative contributions of key hazards associated with major adverse cardiovascular events in patients with coronary stents. These form the framework for clinical decision-making.

32 Van Kuijk P. Am J Cardiol 2009;104:1229 Noncardiac surgery after stent implantation: Antiplatelet therapy and risk of bleeding





37 Clopidogrel was discontinued 5 days before surgery, and hospital admission was planned for the day after the last clopidogrel intake (4 days before surgery), when i.v. tirofiban infusion was started according to the schedule approved for patients with ACS: that is, 0.4 mg kg21 min21 over 30 min, followed by 0.1 mg kg21 min21.15 The tirofiban dose was reduced by 50% if creatinine clearance was,30 ml min21. The infusion was stopped 4 h before surgery (8 h in the case of creatinine clearance,30 ml min21), resumed at the same schedule (including the 30 min bolus) 2 h after the end of surgery, and continued for up to 6 h after the resumption of clopidogrel, unless oral administration could be resumed on the same day as surgery. After surgery, clopidogrel was reintroduced using a loading dose of 300 mg (four tablets) as soon as the patient could resume oral administration, and then continued at a once daily dose of 75 mg. Aspirin (75–100 mg once a day) was ideally to be continued throughout the perioperative period Results: 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. Br J Anaesth 2010; 104: 285–91

38 surgery Day h* 0 4h follow-up until discharge Stop Plavix Stop Plavix Start bridge Start bridge *8h in pts with eGFR <30 ml/min Stop bridge Stop bridge T Resume Bridge** Resume Bridge** Resume Plavix mg*** Resume Plavix mg*** **if oral admin not possible *** as soon as oral admin possible Phase 2 protocol (Simons two stage design) for urgent surgery early after DES Primary EP: the composite of Death, MI, stent thrombosis, haemostatic reoperation 12 months in the case of high-risk of ST: stent implantation due to an ACS diabetes renal insufficiency severe LV dysfunction DES in LMCA, proximal LAD, bifurcation Exclusion criteria · Allergy to tirofiban – eptifibatide · Thrombocytopenia < · Stroke < 30 days or prior ICH · Intracranial disease · Uncontrolled hypertension · Unable to sign consent form Inclusion criteria Patients within 6-12 months of DES implantation + high-risk for surgical bleeding, so that the surgeon would not operate on clopidogrel Aspirin continued throughout Low-dose LMWH for DVT prevention Aspirin continued throughout Low-dose LMWH for DVT prevention Savonitto S. Br J Anaesth 2010;104:285-91

39 Phase 2 bridge study For urgent surgery early after DES: current status PATIENTS ENROLLED56 cardiac19 urinary tract 7 gastrointestinal18 mixed surgery12 PRIMARY ENDPOINT*0 (97.5% C.I. 6.4%) BLEEDING** EVENTSmajor2 minor 3 transf 12 SEVERE § THROMBOCITOPENIA1 * The composite of death+MI+stent thrombosis+haemostatic reoperation **Bleeding according to TIMI criteria: major means Hb decrease >5 g/dL, minor means Hb decrease >3 but <5 g/dL, after correction for transfusion (1 g ofHb for each U transfused); § platelet count <20,000. Urgent surgery after DES.. Savonitto De Servi

40 Early surgery after stent implantation: Anesthesiologist warning

41 Heart, Lung and Circulation 2010;19:2–10


43 CONCLUSIONI I con l aumentare delleta un crescente numero di pazienti va incontro ad interventi di chirurgia non cardiaca al momento dellimpianto di uno Stent (che richiede una DAPT da un minimo di 1 mese ad un massimo di mesi ) devono essere considerati con attenzione il rischio emorragico ed le patologie associate la trombosi di Stent è un evento drammatico con elevata mortalità ed è principalmente determinato dalla interruzione prematura della DAPT Nei pazienti portatori di Stent coronarici lintervento chirurgico dovrebbe essere differito a 3 mesi in caso di BMS e 12 mesi in caso di DES

44 In caso di intervento non differibile ad elevato rischio emorragico in pazienti con elevato rischio trombotico la bridge strategy con agenti antipiastrinici ev a breve durata dazione si e dimostrata efficace nella prevenzione della ST senza aumentare significativamentel e emorragie. limpiego di tale strategia e tuttavia ancora controverso e non indicato dalle linee guida con livello elevato di evidenza Nei pazienti con eccessivo sanguinamento peri-operatorio sono indicati trasfusioni di piastrine e agenti pro emostatici Nuovi farmaci quali il Ticagrelor ( breve emivita ) potrebbero in futuro costituire un alternativa allimpiego degli inibitori del II b- III a ( piccole molecole ).

45 Gurbel P. Circulation 2009, published online Nov 19 Ticagrelor vs clopidogrel: time course of IPA by 20 M/L ADP

46 Reversibility of platelet inhibition Oral drugaspirinclopidogrelprasugrelticagrelor Reversibility i rreversible reversible Time to surgery 5-7 days 3 days? i.v. drugabciximabtirofibaneptifibatide Reversibilityirreversiblereversible Time to surgery 3-5 days4 hours (8 hours if CrCl <30 ml) 4 hours




50 Kwok A. et al. Am J Gastroenterol online pubblication, 11 August 2009; doi: /ajg GESTIONE ANTIAGGREGANTI IN PROCEDURE ENDOSCOPICHE GI

51 Healthy volunteer crossover study IPA (20 M ADP) at 24 hours Brandt J et al. AHJ 2006 – Inhibition of platelet aggregation (%) Response to prasugrel 60 mg Response to clopidogrel 300 mg N=64

52 Gum PA et al. Am J Cardiol 2001;88: ASA-R: mean aggregation 70% with µM 10 ADP & 20% with 0.5 mg/ml AA 325 patients with stable CVD taking ASA 325 mg >7days Prevalence of ASA Resistance

53 Biondi-Zoccai GGL, et al. Eur Heart J : La sospensione degli Antiaggreganti Sospensione ASA in coronaropatici Aumentato Rischio Trombotico




57 Conclusions on DAPT and surgical risk For surgical and endoscopic procedures at HR of bleeding, DAPT represents a serious issue. Withdrawal of DAPT + post-surgical haemostatic activation + malignancy increase severalfold the risk of ST and death, THE POST-OPERATIVE FASE BEING THE MORE DANGEROUS. Based on the results of our ongoing experience, we propose that a bridge strategy using short-acting i.v. antiplatelet agents confers protection against perioperative CV events that goes beyond the prevention of ST, without increasing the risk of surgical bleeding. Among the new P2Y 12 antagonist, the reversible blocker ticagrelor might reduce by 1-2 days the duration of pre- operative withdrawal, but its use in the early post-op days should be studied, and sofar it hasnt been shown to reduce bleeding compared to clopidogrel. The concept of platelet anaesthesia should be further explored

58 Early surgery after stent implantation: Step 2: risk stratification for stent thrombosis

59 Heart, Lung and Circulation 2010;19:2–10


61 Tutti gli stent coronarici richiedono un periodo di DAPT post- impianto: 4 settimane i BMS, 6-12 mesi i DES. Ciò al fine di prevenire la trombosi di stent (morte-infarto nel 50-70% dei casi) La terapia antiaggregante aumenta il rischio emorragico in chirurgia generale, laparoscopica, e durante procedure endoscopiche La sospensione della terapia antiaggregante prima che sia finito il periodo di vulnerabilità espone al rischio di trombosi di stent, aumentato dall effetto pro-trombotico della chirurgia Pazienti con STENT coronarici che devono essere sottoposti a chirurgia non cardiaca surgery, either elective or urgent, poses a largely unsolved problem for patients on dual antiplatelet therapy and their treating physicians. Schulz S. Eur Heart J 2009;30:2714

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