How to manage patients with need for antiplatelet therapy in the setting of (un-)planned surgery

The Association of Body Mass Index with Surgical Time Is Mediated by Comorbidity in Patients Undergoing Total Hip Arthroplasty

Overweight represents a major issue in contemporary orthopaedic practice. A higher body mass index (BMI) is associated with an increase of perioperative complications following several orthopaedic procedures, in particular total hip arthroplasty (THA). However, the influence of overweight on THA surgical time is controversial. In this study, we investigated the association between BMI and surgical time analyzing the role of patients’ comorbidities. We conducted a retrospective study on 748 patients undergoing THA at our institutions between 2017 and 2018. Information regarding medical diseases was investigated and the burden of comorbidity was quantified using the Charlson score (CCI). Surgical time and blood loss were also recorded. Median surgical time was 76.5 min. Patients with surgical time above the median had both a higher BMI (28.3 vs. 27.1 kg/m²; p = 0.002); and CCI (1 vs. 0; p = 0.016). According to linear regression, surgical time was associated with BMI in the unadjusted model (p < 0.0001), after adjusting for age and sex (p < 0.0001), and in the multivariable model (p = 0.005). Furthermore, BMI was associated with increased surgical time only in patients with a Charlson score above the median, but not in others. Obesity is associated with increased surgical time during THA, especially in pluricomorbid patients, with a higher risk of perioperative complications.

Is continuation of anti-platelet treatment safe for elective total hip arthroplasty patients?

INTRODUCTION

Acetylsalicylic acid (aspirin) is a commonly prescribed medication, especially in the age group of individuals who undergo elective total hip arthroplasty (THA). Preoperative discontinuation of aspirin is believed to reduce intraoperative bleeding and other complications, but it may increase the risk of perioperative cardiovascular events. In this study we have sought to evaluate the safety of continuous aspirin treatment in patients undergoing elective THA.

MATERIALS AND METHODS

This is a retrospective analysis of a consecutive cohort who underwent elective THA in a tertiary medical center between 2011 and 2018. The cohort was divided into two groups-one that received continuous preoperative aspirin treatment and one that did not. Blood loss, peri- and postoperative complications, readmissions, and short- and long-term mortality were compared between groups.

RESULTS

Out of 757 consecutive patients (293 males, 464 females) who underwent elective primary THA, 552 were in the "non-aspirin" group and 205 were in the "aspirin" group and were not treated preoperative with other medication affecting hemostasis. Perioperative continuation of aspirin treatment did not significantly increase perioperative bleeding, as indicated by changes in hemoglobin levels (P = 0.72). There were no significant differences in short- and long-term mortality (P = 0.47 and P = 0.4, respectively) or other perioperative complications, such as readmission (P = 0.78), deep or superficial infection (P = 1 and P = 0.47, respectively), and cardiovascular events (none in both groups).

CONCLUSION

Peri-operative continuation of aspirin treatment in patients undergoing elective primary THA did not increase perioperative complications or mortality compared to the non-aspirin-treated patients. The protective effects of aspirin from postoperative thrombotic and cardiovascular events are well documented. The current findings dispute the need to preoperatively withhold aspirin treatment in patients undergoing elective primary THA.

Perioperative dual antiplatelets management for ventriculoperitoneal shunt operation in patients with hydrocephalus after stent-assisted coil embolization of the ruptured intracranial aneurysm

OBJECTIVE

Ventriculoperitoneal shunt (VPS) surgery is sometimes necessary in patients who present with symptomatic hydrocephalus after undergoing stent-assisted coil embolization of ruptured intracranial aneurysms. However, there are no guidelines for the perioperative management of VPS using dual antiplatelet therapy (DAPT) and balancing between the thromboembolic and hemorrhagic complications. Studies regarding discontinuation of DAPT and its substitution with a less potent drug for reducing the risk of hemorrhage have been previously attempted; however, the sample size in these studies was small. This study investigates the safety and feasibility of ibuprofen bridging therapy with discontinuation of DAPT for five days in patients who have recently received a neurovascular stent and require VPS.

METHODS

Forty-one patients, who were administered DAPT after neurovascular stent placement and later underwent VPS, were retrospectively enrolled. Patients were divided into two groups based on the perioperative DAPT therapy: (1) Bridge: discontinuing DAPT and substituting it with ibuprofen 600 mg bid for five days, and (2) Continue: maintaining DAPT during surgery. The groups were compared and risk factors for hemorrhagic complication were investigated.

RESULTS

On comparison analysis, no ischemic complications were observed in both groups; however, hemorrhagic complications were significantly higher in the continue than in the bridge group (p = 0.004). On multivariate logistic regression analysis, "ibuprofen bridging" was identified as a significant factor negatively associated with hemorrhagic complications (p = 0.019).

CONCLUSION

"Ibuprofen bridging therapy with discontinuation of DAPT for 5 days" is a potential treatment strategy for patients having recently undergone neurovascular stent placement and are scheduled for VPS surgery.

Post-extraction bleeding complications in patients on uninterrupted dual antiplatelet therapy-a prospective study

BACKGROUND

Dental surgeons consider patients on antiplatelet therapy (APT) to be at a risk for perioperative bleeding during dental extraction. This fear often prompts them to consider a temporary withdrawal of the medication for a few days before extraction. Such withdrawal can have serious consequences, especially in patients on dual antiplatelet therapy (DAPT).

OBJECTIVES

The purpose of this study was to analyze if patients on uninterrupted DAPT undergoing dental extractions had an increased risk of bleeding complications when compared with patients on no antiplatelet therapy.

METHODS

This prospective study included 120 DAPT patients and an equal number of age- and gender-matched non-APT patients undergoing dental extractions. Immediate and delayed bleeding complications in both groups were recorded. Interventions required to control the post-extraction hemorrhage were also analyzed.

RESULTS

Duration of DAPT medication ranged from 6 months to 13 years. Post-percutaneous coronary intervention was the most common cause for DAPT. A vast majority of patients in both groups underwent extraction of one or two teeth. Patients on DAPT had a 7-fold increased risk of immediate bleeding complications when compared with control group. All bleeding episodes were controlled with local hemostatic measures. Transalveolar extractions and localized periodontitis had a significant relationship to bleeding complications.

CONCLUSION

This study observed an increase in the risk of prolonged bleeding in uninterrupted DAPT patients undergoing dental extractions. Bleeding episodes were amenable to local hemostatic measures with favorable outcomes.

CLINICAL RELEVANCE

Dental extractions in patients on uninterrupted DAPT can be done safely. Resorting to temporary withdrawal of DAPT due to a fear of excessive bleeding is unnecessary.

Comparing the short - term outcomes and complications of monopolar and bipolar transurethral resection of bladder tumors in patients with coronary artery disese: a prospective, randomized, controlled study

INTRODUCTION

To compare the perioperative outcomes and complications of monopolar and bipolar transurethral resection of bladder tumors (TURBT) in patients with coronary artery disease (CAD).

MATERIALS AND METHODS

A total of 90 CAD patients with newly diagnosed bladder cancer who underwent TURBT were randomized into monopolar TURBT (M-TURBT) and bipolar TURBT (B-TURBT) groups. Primary outcome was safety of the procedures including obturator jerk, bladder perforation, clot retention, febrile urinary tract infection and TUR syndrome. The secondary outcome was the efficacy of TURBT procedures, including complete tumor resection, sampling of the deep muscle tissue and sampling of the qualified tissues without any thermal damage.

RESULTS

Mean ages of the patients in M-TURBT and B-TURBT groups were 71.36±7.49 and 73.71±8.15 years, respectively (p=0.157). No significant differences were found between M-TURBT and B-TURBT groups regarding complete tumor resection (76.2% vs. 87.5%, p=0.162) and muscle tissue sampling rates (71.4% vs. 64.6%,p=0.252). Obturator jerk was detected in 16.7% of the patients in M-TURBT group and 2.1% in B-TURBT group (p=0.007). No statistically significant differences were found between the groups regarding intraoperative and postoperative complications.

CONCLUSIONS

Both monopolar and bipolar systems can be used safely and effectively during TURBT procedure in CAD patients. Due to the more frequently seen obturator jerk in M-TURBT than B-TURBT, careful surgical approach is needed during M-TURBT.

Treatment of ruptured blood blister aneurysms using primary flow-diverter stenting with considerations for adjunctive coiling: A single-centre experience and literature review

Objective The objective of this article is to conduct a single-centre evaluation and quick literature review of the effectiveness of primary flow-diverter (FD) treatment of ruptured blood blister aneurysms (BBAs), with additional relevance of adjunctive coiling. Methods Patients presenting with subarachnoid haemorrhage (SAH) due to ruptured BBAs and subsequently treated with FDs were retrospectively selected from June 2010 to January 2017. Treatment techniques, angiographic data on occlusion rates and procedural success as well as clinical outcomes using the modified Rankin Scale (mRS) were collated. Cross-reference of results were made with available literature. Results Thirteen patients harbouring 14 BBAs were recruited. Of the 14 aneurysms, five (35.7%) showed immediate complete occlusion after the procedure (four of these five patients had adjunctive coiling). All of the aneurysms showed complete occlusion by the six- to nine-month control diagnostic angiogram. No rebleed or retreatment was experienced. Twelve of 13 (92%) patients had an mRS score of 0-1 at the last clinical follow-up. From the pooled data of the literature review, eventual aneurysm occlusion was achieved in 48/56 patients, with five patients requiring further endovascular treatment. In the clinical follow-up period, an mRS of 0-2 was recorded for 83.3% (45/54) of patients. Conclusion Endovascular reconstruction of BBAs using FD treatment is an effective method with good final clinical outcomes. Adjunctive use of coiling achieves higher incidence of immediate complete occlusion of BBAs.

One-Year Mortality, Causes of Death, and Cardiac Interventions in Patients with Postoperative Myocardial Injury

BACKGROUND

To evaluate the role of routine troponin surveillance in patients undergoing major noncardiac surgery, unblinded screening with cardiac consultation per protocol was implemented at a tertiary care center. In this study, we evaluated 1-year mortality, causes of death, and consequences of cardiac consultation of this protocol.

METHODS

This observational cohort included 3224 patients ≥60 years old undergoing major noncardiac surgery. Troponin I was measured routinely on the first 3 postoperative days. Myocardial injury was defined as troponin I >0.06 μg/L. Regression analysis was used to determine the association between myocardial injury and 1-year mortality. The causes of death, the diagnoses of the cardiologists, and interventions were determined for different levels of troponin elevation.

RESULTS

Postoperative myocardial injury was detected in 715 patients (22%) and was associated with 1-year all-cause mortality (relative risk [RR] 1.4, P = 0.004; RR 1.6, P < 0.001; and RR 2.2, P < 0.001 for minor, moderate, and major troponin elevation, respectively). Cardiac death within 1 year occurred in 3%, 5%, and 11% of patients, respectively, in comparison with 3% of the patients without myocardial injury (P = 0.059). A cardiac consultation was obtained in 290 of the 715 patients (41%). In 119 (41%) of these patients, the myocardial injury was considered to be attributable to a predisposing cardiac condition, and in 111 patients (38%), an intervention was initiated.

CONCLUSIONS

Postoperative myocardial injury was associated with an increased risk of 1-year all-cause but not cardiac mortality. A cardiac consultation with intervention was performed in less than half of these patients. The small number of interventions may be explained by a low suspicion of a cardiac etiology in most patients and lack of consensus for standardized treatment in these patients.

Comparison of preoperative continuation and discontinuation of aspirin in patients undergoing total hip or knee arthroplasty

INTRODUCTION

Preoperative discontinuation of aspirin (acetylsalicylic acid) can reduce bleeding risk but may increase the risk of perioperative cardiovascular events.

MATERIALS AND METHODS

We retrospectively assessed the impact of preoperative continuation versus discontinuation of aspirin compared with a control group in a cohort of 739 consecutive patients undergoing total hip (THA) (n = 396) or knee arthroplasty (TKA) (n = 343) at a tertiary hospital. Bleeding risk, local complications, orthopaedic outcome, and cardiac and cerebral complications were assessed.

RESULTS

Four hundred and sixty-five patients did not receive antithrombotic or full-dose anticoagulant medication, 175 patients were taking low-dose aspirin, 99 vitamin K antagonists, clopidogrel, or a combination of these drugs. Of the patients taking aspirin, 139 discontinued and 36 continued aspirin. Blood loss and local bleeding complications were comparable in these two groups. TKA patients who continued aspirin more frequently showed marked knee swelling after 1 week than those discontinuing aspirin (35.1 vs. 81.3 %; p = 0.001). However, orthopaedic outcome did not differ significantly between the two groups. There was a trend towards an increased risk of cardiac complications in patients who discontinued aspirin (6.5 vs. 0.0 %; p = 0.107).

CONCLUSIONS

Continuation or discontinuation of aspirin did not show a statistically significant difference in the risk of relevant perioperative bleeding complications in our study. Continuation of aspirin was associated with a transitory increase in knee swelling, but had no effect on orthopaedic outcome. Continuation of aspirin may be associated with a favourable perioperative cardiac outcome. Our data support perioperative continuation of aspirin intake in patients undergoing THA or TKA.

[ASA and clopidogrel for urological operations. Perioperative management]

In a systematic overview and meta-analysis among more than 50,000 patients at risk for coronary artery disease, not adhering to or discontinuing aspirin (acetylsalicylic acid, ASA) was associated with a significantly increased risk of non-fatal myocardial infarction or death. Withdrawal of low dose aspirin was correlated with a threefold increase in the risk of adverse cardiovascular events. This risk is present irrespective of the length of time patients had been taking low dose aspirin. Therefore, in patients on chronic low dose aspirin for secondary prevention of cardiovascular disease, aspirin should never be discontinued. In the few available studies in urological surgery the increase in bleeding does not translate into a significant increase in specific morbidity. This seems to be also true for the additional administration of clopidogrel to aspirin. Nevertheless, in patients with drug-eluting stents and dual antiplatelet therapy, urologists should ensure a multidisciplinary management of the perioperative course.

Risks and complications of transurethral resection of bladder tumor among patients taking antiplatelet agents for cardiovascular disease

BACKGROUND

Urologists have not reached a consensus regarding the pre-, intra-, and postoperative management of patients taking antiplatelet agents. This study aimed to evaluate the clinical course of patients receiving antithrombotic monotherapy with acetylsalicylic acid (ASA) 100 mg who underwent transurethral resection of bladder cancer.

METHODS

This study was designed to compare the surgical outcomes for 108 transurethral resections of bladder cancer performed for patients taking antiplatelet therapy and for 105 procedures performed for patients who had never taken antiplatelet agents before surgery. Antiaggregant therapy was maintained according to criteria evaluated by a urologist, surgeon, anesthesiologist, and cardiologist. Variables were described using the mean as the location index and using standard deviation as a dispersion index if continuous percentages were used elsewhere. Group comparisons were performed using the t test or the chi-square test for categorical data, and Fisher's exact test was used where appropriate.

RESULTS

The mean operative time for patients taking ASA was 31 min (range 10-65 min), whereas it was 26 min (range 5-60 min) for control subjects. The difference between pre- and postoperative hemoglobin values was -0.6 g/dl in the group receiving antiplatelet therapy and -0.8 g/dl in the control group (p = 0.0720). Transfusional support was required during four procedures performed for patients taking antiplatelet therapy and during two procedures for the control group (p = 0.242). No adverse cardiac events or anesthesia-related complications occurred. Three patients in the treatment group and two patients in the control group required reintervention to ensure hemostasis during the postoperative period. None of the patients in either group underwent rehospitalization for hematuria after leaving the hospital.

CONCLUSION

The current results suggest that continued use of anti-aggregant monotherapy does not increase the risk of overall bleeding or reintervention for patients undergoing transurethral resection of bladder neoplasms and that suspending aspirin before such a procedure is therefore unnecessary.

Antithrombotic or anti-platelet agents in patients undergoing permanent pacemaker implantation

Background and Objectives

The growing implantations of electrophysiological devices in the context of increasing rates of chronic antithrombotic therapy in cardiovascular disease patients underscore the importance of an effective periprocedural prophylactic strategy for prevention of bleeding complications. We assessed the risk of significant bleeding complications in patients receiving anti-platelet agents or anticoagulants at the time of permanent pacemaker (PPM) implantation.

Subjects and Methods

We reviewed bleeding complications in patients undergoing PPM implantation. The use of aspirin or clopidogrel was defined as having taking drugs within 5 days of the procedure and warfarin was changed to heparin before the procedure. A significant bleeding complication was defined as a bleeding incident requiring pocket exploration or blood transfusion.

Results

Permanent pacemaker implantations were performed in 164 men and 96 women. The mean patient age was 73±11 years old. Among the 260 patients, 14 patients took warfarin (in all of them, warfarin was changed to heparin at least 3 days before procedure), 54 patients took aspirin, 4 patients took clopidogrel, and 25 patients took both. Significant bleeding complications occurred in 8 patients (3.1%), all of them were patients with heparin bridging (p<0.0001). Heparin bridging markedly increased the length of required hospital stay when compare with other groups and the 4 patients (1.5%) that underwent the pocket revision for treatment of hematoma.

Conclusion

This study suggests that hematoma formation after PPM implantation was rare, even among those who had taken the anti-platelet agents. The significant bleeding complications frequently occurred in patients with heparin bridging therapy. Therefore, heparin bridging therapy was deemed as high risk for significant bleeding complication in PPM implantation.

Perioperative management of a neurosurgical patient requiring antiplatelet therapy

In patients who undergo neurovascular stent placement with postoperative dual antiplatelet therapy to prevent in-stent thrombosis, there is no protocol for balancing the risk of acute stent thrombosis and bleeding if urgent neurosurgical procedures are required. We detail perioperative management of dual antiplatelet therapy in a 66-year-old man with a dolichoectatic aneurysm of the basilar artery treated with a Pipeline stent. Postoperatively, the patient was placed on aspirin and clopidogrel to prevent in-stent thrombosis. One month after the procedure, his neurological status declined secondary to obstructive hydrocephalus. His condition necessitated urgent placement of a ventriculoperitoneal shunt, despite the dual antiplatelet therapy for the flow-diverting Pipeline stent. Aspirin and clopidogrel were discontinued seven days prior to the planned shunt placement. To minimize time off antiplatelet therapy, aspirin was immediately replaced with ibuprofen. Eptifibatide was then started three days prior to surgery. The ibuprofen/eptifibatide bridge was discontinued at midnight prior to surgery. Aspirin was restarted on the first postoperative day and clopidogrel was restarted on the second postoperative day. The patient tolerated shunt placement without excessive bleeding or hemorrhagic complications. During the remainder of his hospital course, no evidence of stent thrombosis or intracranial hemorrhage was noted. We conclude that management of antiplatelet prophylaxis for neurovascular stent thrombosis in patients requiring urgent neurosurgical procedures may be successfully achieved by bridging aspirin and clopidogrel with ibuprofen and eptifibatide in the preoperative period.

Anticoagulation and antiplatelet therapy in implantation of electrophysiological devices

The growing implantations of electrophysiological devices in the context of increasing rates of chronic antithrombotic therapy in cardiovascular disease patients underscore the importance of an effective periprocedural prophylactic strategy for prevention of bleeding complications. In this review, we provide a concise overview of the data regarding anticoagulation and antiplatelet therapy in arrhythmia device surgery. Also, we critically discuss risk factors and procedural parameters that are potentially associated with haemorrhagic untoward events in this setting. Of note, current evidence suggests that heparin bridging therapy in patients on chronic anticoagulation and dual-antiplatelet therapy are associated with increased risk of pocket haematoma formation. Continuation of oral anticoagulation and short-term interruption of clopidogrel with aspirin maintenance in eligible patients, respectively, represent promising strategies with an acceptable safety profile. Besides the perioperative management of antithrombotic therapy, some extra supportive measures may also reduce the incidence of haematomas. High-risk cases should be better treated by experienced operators in high-volume centres. More randomized studies are needed to elucidate the exact role of particular antithrombotic therapy protocols. Finally, the recently accumulated data on this subject should be incorporated into the professional guidelines regarding arrhythmia device therapy.

[Diagnostic laparoscopy under dual antiplatelet therapy with clopidogrel and aspirin]

Dual antiplatelet therapy using aspirin and a thienopyridine (e.g. clopidogrel) is known to be essential in patients in whom percutaneous coronary intervention with stent implantation has been performed in order to prevent stent thrombosis and its fatal consequences. On the other hand dual antiplatelet therapy increases the incidence of perioperative bleeding complications. In case of urgent or emergency surgery the risk of perioperative stent thrombosis on the one hand and the perioperative bleeding risk on the other has to be evaluated carefully in order to keep time period without sufficient platelet inhibition as short as possible. The presented case offers a strategy for managing perioperative administration of antiplatelet agents.

The Management of Antiplatelet Therapy in Patients With Coronary Stents Undergoing Noncardiac Surgery

Whereas the development of coronary stents has been a major breakthrough in the treatment of coronary artery disease, stent thrombosis, associated with myocardial infarction and death, has introduced a new challenge in the care of patients with coronary stents undergoing noncardiac surgery. This review presents the authors’ recommendations regarding the optimal management of such patients. Elective surgery should be postponed for at least 6 weeks and optimally 3 months for a bare-metal stent and at least 1 year for a drug-eluting stent. On the other hand, managing a patient undergoing non-elective surgery is more difficult and necessitates a case-by-case assessment of bleeding risk versus thrombotic risk based on patient comorbidities, type of stents present, details of the coronary intervention, and type of surgical procedure. Patients with a risk of bleeding that outweighs the risk of stent thrombosis should discontinue at least clopidogrel, whereas all other patients should continue dual antiplatelet therapy throughout the perioperative period.