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

Br J Anaesth. 2010 Mar;104(3):285-91. doi: 10.1093/bja/aep373. Epub 2010 Jan 3.

Abstract

Background: 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 Clopidogrel was to be withdrawn 5 days before surgery, and tirofiban started 24 h later, continued until 4 h before surgery, and resumed 2 h after surgery until oral clopidogrel was resumed.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.

Publication types

  • Clinical Trial, Phase II

MeSH terms

  • Adult
  • Aged
  • Aged, 80 and over
  • Angioplasty, Balloon, Coronary
  • Blood Loss, Surgical / prevention & control
  • Clopidogrel
  • Coronary Restenosis / prevention & control
  • Coronary Thrombosis / prevention & control
  • Drug Administration Schedule
  • Drug-Eluting Stents / adverse effects*
  • Emergencies
  • Female
  • Hemostasis, Surgical / methods
  • Humans
  • Male
  • Middle Aged
  • Perioperative Care / methods*
  • Pilot Projects
  • Platelet Aggregation Inhibitors / adverse effects
  • Platelet Aggregation Inhibitors / therapeutic use*
  • Prospective Studies
  • Substance Withdrawal Syndrome / drug therapy
  • Ticlopidine / adverse effects
  • Ticlopidine / analogs & derivatives*
  • Tirofiban
  • Tyrosine / analogs & derivatives*
  • Tyrosine / therapeutic use

Substances

  • Platelet Aggregation Inhibitors
  • Tyrosine
  • Clopidogrel
  • Tirofiban
  • Ticlopidine