围术期抗血小板治疗的相关问题

目前对冠状动脉硬化尤其是植入冠状动脉支架的病人采用抗血小板药物治疗,抑制血小板的黏附、聚集和释放,对心脏意外事件的预防取得较好效果[1,2].但外科、麻醉科医师对植入冠状动脉支架病人拟行非心脏手术前是否停用抗血小板药物及相关病人面临的围术期栓塞/出血问题仍存有争议,现就有关问题进行报道.     

冠状动脉旁路移植术后短期内应用强化他汀对患者出血风险的研究

目的观察冠状动脉旁路移植术后短期内应用强化他汀治疗对患者出血风险的影响。方法 接受冠状动脉旁路移植术治疗的患者240例,将240例患者随机分成试验组和对照组,各120例。两组患者均规范化给予药物常规治疗,在围手术期均予以低分子量肝素抗凝治疗。试验组在术前给予40 mg/d阿托伐他汀,顿服,术后40 mg/d,口服1个月;对照组在手术前后一直以10 mg阿托伐他汀口服治疗,服药1个月后,比较两组患者血小板聚集率及出血情况。结果术后试验组患者血小板最大聚集率为(14.5±3.7)%,血小板聚集抑制率为(79.5±4.3)%,术后出血发生率为27.5%。对照组分别为(38.1±7.4)%、(50.8±10.2)%和12.5%,两组比较差异均有统计学意义(P0.05)。结论冠状动脉旁路移植术后短期内应用强化他汀治疗可导致出血风险增加。     

冠心病合并外周动脉硬化病变的联合介入治疗

目的探讨冠心病合并外周动脉硬化病变的联合介入治疗的近期效果及安全性。方法对2013-01—2015-09间收治的57例冠心病合并外周动脉硬化病变患者行常规抗血小板治疗,加强血糖控制,稳定血压,并持续性服用他汀类药物。依据患者病情状况及症状分别或同时采取冠状动脉介入治疗(PCI)与外周动脉介入治疗(PPI)。观察记录治疗期间并发症及不良心脏事件发生情况。随访3~6个月,行血管造影复查冠状动脉狭窄率。结果对124处冠状动脉靶病变采取PIC介入治疗,共计植入冠状动脉支架135枚,每例植入1~4枚;PCI介入治疗即刻成功率100%。患者术后心绞痛症状及时缓解有效率98.25%(56/57),仅1例术后未完全血运重建,伴有轻度心绞痛,在采取抗凝治疗同时应用硝酸酯类、β受体阻断剂等药物抗心肌缺血治疗后症状消失。PPI治疗靶血管89支,共植入89枚外周动脉支架,每例植入1~2枚;其中PCI、PPI共同次治疗22例,余下35例均为单次择期治疗,PPI介入治疗即刻成功率高100%。患者治疗期间均未发生急性心肌梗死、脑梗死等不良心脏事件,仅2例术后出现一过性肾功能不全,后经对症处理后痊愈,患者均存活出院。结论对冠心病合并外周动脉硬化病变患者采取联合介入治疗,可提高治疗效果,降低术后并发症发生率,为患者后期动脉严重狭窄病变的防治提供保障。     

冠状动脉支架植入术后Stanford A型主动脉夹层的外科治疗

目的 分析冠状动脉支架植入术后Stanford A型主动脉夹层患者的外科治疗方式,探讨其手术技术及手术时机。方法 回顾性分析2016年4月—2019年7月首都医科大学附属北京安贞医院连续收治的1 246例Stanford A型主动脉夹层患者的临床资料。纳入冠状动脉支架植入术后Stanford A型主动脉夹层患者。结果 最终纳入患者19例,其中男16例、女3例,年龄35～66(54±7)岁。19例患者中急性主动脉夹层11例。AC型（DeBakeyⅠ型）主动脉夹层15例,AS型（DeBakeyⅡ型）4例。AC型患者中行孙氏手术（全弓置换+支架象鼻手术）10例,部分弓置换5例;19例患者中同期行冠状动脉旁路移植术7例,二尖瓣置换术1例;4例患者术中取出位于右冠开口的支架。本组住院死亡1例,主因术前合并脏器灌注不良,术后死于多脏器功能衰竭。18例患者经治疗后痊愈出院,平均随访30(18～56)个月,其中1例因冠状动脉吻合口漏行二次漏修补术,1例因远端夹层新发破口行胸主动脉腔内修复,1例因左主干支架闭塞急诊行经皮冠状动脉介入治疗,1例因髂动脉闭塞行股股转流。结论 冠状动脉支架植入术后Stanfo...     

冠脉支架患者非心脏手术的围手术期处理

背景 近三十年来,心脏冠脉支架患者日益增多,此类患者在接受非心脏手术时其围手术期将面临特殊挑战.目的 现将重点讨论支架血栓的病理生理以及冠脉支架患者非心脏手术围手术期的处理策略.内容 冠脉支架患者为预防支架内血栓的发生,通常接受由阿司匹林和氯吡格雷为主要药物的双联抗血小板治疗,其疗程为裸金属支架bare metal s...     

心脏移植治疗终末期冠心病五例

目的总结心脏移植治疗终末期冠心病的体会。方法共有5例患者,1例为2次急性心肌梗死后行左心辅助泵植入术后25个月的患者,3例为急性心肌梗死后大面积无存活心肌、出现心力衰竭的患者,1例为经皮冠状动脉支架置入术和冠状动脉旁路移植术后仍反复发生心力衰竭的患者。均施行标准式原位心脏移植术。术前使用达利珠单抗诱导治疗1次,术后采用环孢素A、霉酚酸酯和泼尼松预防急性排斥反应。结果5例患者均痊愈出院,恢复正常的生活和工作,心功能均恢复至Ⅰ级;术后未发生严重的感染和急性排斥反应。结论心脏移植可作为治疗不适宜施行冠状动脉旁路移植术,或冠状动脉旁路移植术后效果较差的终末期冠心病患者的有效手段;选择合适的供心、良好的心肌保护、合理的抗排斥治疗方案,以及围手术期血压、血糖、血清胆固醇、尿酸的有效控制,是手术成功的关键。     

主支支架术＋边支球囊扩张治疗冠状动脉分叉病变的疗效和安全性

目的观察冠状动脉分叉病变患者行主支支架置入术＋边支球囊扩张术的临床疗效和安全性。方法 110例冠状动脉分叉病变患者,采用主支置入支架,边支球囊扩张的手术策略,观察手术对分支血管的影响、临床疗效及主要不良心血管事件发生率。结果手术后即刻成功率98.1%（108/110）,主支置入支架120支,对边支球囊扩张80例,边支置入支架4支。2例（6支）患者支架不能通过,主支未放入支架,手术使边支血管受压发生率为13.3%（20/150）。100例术后获随访,术后6个月随访无症状者95.0%（95/100）,发生稳定型心绞痛2例（2%）,无不良心血管事件发生。结论冠心病分叉病变采用仅主支置入支架＋边支球囊扩张的手术策略,对边支血管影响小,短期观察安全有效。     

冠状动脉支架术后胆囊炎胆结石发作患者的腹腔镜胆囊切除术

目的探讨冠状动脉支架术后行腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）的可行性、安全性。方法2003年1月~2008年12月对冠状动脉支架术后32例结石性胆囊炎采取低流量（〈2 L/min）、低压力（8~12 mm Hg）或间断气腹法行三孔LC。手术前后采用肝素暂时替代抗血小板药物。结果32例LC顺利完成,手术时间20~90 min,（45.6±20.4）min;术中出血量30~150 ml,平均65.2 ml。术后无胆汁漏,切口一期愈合。32例术后随访0.5~2年,平均1.1年,支架内再狭窄率0.3%（1/32）。结论冠状动脉支架术后的胆囊炎胆结石患者经适当处理,在低气腹压力下行腹腔镜胆囊切除术并尽量缩短手术时间,是可行、安全的。     

双联抗血小板治疗对冠状动脉旁路移植术后出血及输血的影响

目的评价术后早期应用阿司匹林加氯吡格雷双联抗血小板治疗对冠状动脉旁路移植术(CABG)术后出血及输血的影响。方法将2007年12月至2008年12月期间在我院成功接受CABG的249例患者,随机分配到阿司匹林组(A组)和阿司匹林加氯吡格雷组(AC组),A组125例(口服阿司匹林100mg/d),AC组124例(口服阿司匹林100mg/d+氯吡格雷75mg/d);入选患者在术后48h内开始抗血小板治疗。比较两组患者术前临床基线资料,术中、术后情况;记录两组患者术后胸腔引流量、血液及血液制品使用量。通过线性回归模型进行多因素分析,确定影响术后胸腔引流量增加的相关危险因素。结果两组患者术前、术中的临床基线资料比较差异无统计学意义(P0.05);A组和AC组给予抗血小板药物后的胸腔引流量比较差异无统计学意义(495.00±270.89mlvs.489.25±316.68ml,t=0.146,P=0.884);A组和AC组输血例数(81例vs.91例,χ2=1.937,P=0.164)、红细胞用量(2.51±2.88Uvs.2.25±2.87U,t=0.690,P=0.491)及血浆用量(195.45±300.88mlvs.223.01±238.68ml,t=0.759,P=0.449)比较差异无统计学意义。两组患者中均未发生围术期死亡、二次开胸止血或严重的胸外出血情况。多元线性回归分析显示:术后早期应用双联抗血小板治疗与术后胸腔引流量之间无显著相关性(r=2.297,95%CI:-64.526,69.121,P=0.946)。结论遵循事先确定的给药方案,在CABG术后早期应用阿司匹林加氯吡格雷不会导致术后出血的增加。     

经肱动脉穿刺杂交手术治疗髂总动脉起始部闭塞17例分析

目的探讨经肱动脉穿刺入路治疗髂股动脉长段闭塞的安全性及有效性。方法回顾性分析2013-09—2016-01间经肱动脉穿刺入路手术治疗17例髂总动脉闭塞病的临床及随访资料。观察手术效果、并发症及远期通畅情况。结果 17例髂总动脉闭塞患者手术开通率为94.12%,术后患者的ABI值较术前增加(0.46±0.17)。术后无支架相关急性事件,发生穿刺部位皮下血肿1例,术后2个月因停用抗血小板药物出现支架闭塞1例,术后18个月出现支架处狭窄1例。结论经肱动脉穿刺手术治疗髂股动脉长段闭塞,有较高的安全性和成功率。     

Antiplatelet therapy and coronary stents in perioperative medicine--the two sides of the coin

New trends in interventional cardiology, e.g. the increasing practice of coronary intervention with stent implantation and the prolonged use of dual antiplatelet therapy--usually a combination of clopidogrel and aspirin--has also increased the number of patients presenting for non-cardiac surgery. The two most commonly used stent types, bare-metal stents (BMSs) and drug-eluting stents (DESs), mandate different lengths of dual antiplatelet drug therapy to avoid stent thrombosis. Perioperative caregivers face a knife-edge dilemma between perioperative stent thrombosis, due to preoperative discontinuation of antiplatelet drugs, or surgical bleeding, by continuation of therapy. Pre- and intraoperatively, the risk factors for thrombosis have to be balanced against the risk factors for surgical bleeding. As long as prospective trials are not available, the recommendations and guidelines of task forces and experts are based on retrospective studies and case reports. The perioperative management, decision trees and the importance of close interdisciplinary collaboration between cardiologists, surgeons and anaesthetists will be described.     

The Management of Patients on Dual Antiplatelet Therapy Undergoing Orthopedic Surgery

Cardiovascular disease is prevalent in patients undergoing orthopedic surgery. Many patients who have undergone previous percutaneous coronary intervention (PCI) with stenting are on dual antiplatelet therapy in order to minimize the risk of stent thrombosis. The optimal management of these patients in the perioperative setting remains unclear. We aim to provide information about the management of patients who have undergone a PCI with stents who are subsequently indicated for an orthopedic procedure. We will review the concerns from a cardiologist's and orthopedic surgeon's perspective in regards to the management of these patients in the perioperative setting. In addition, the current American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, and American College of Surgeons guidelines are reviewed. The decision to discontinue dual antiplatelet therapy in a patient who has undergone a PCI with stent should be made only after careful review of the risks for thrombosis and bleeding. Best practice suggests that these risks should be jointly assessed by the orthopedic surgeon and cardiologist. Those patients with stents at high risk of thrombosis should have surgery delayed if possible. There is little data supporting a significantly increased bleeding risk associated with mortality in orthopedic patients when antiplatelet therapy is continued perioperatively.     

Platelet function: new drugs, new assays : possible impacts on operative medicine?

Dual antiplatelet therapy with aspirin and a P2Y12 receptor blocker is a well-established strategy to prevent thrombotic complications in patients with acute coronary syndromes (ACS) and after percutaneous coronary interventions (PCI). Current practice guidelines for antiplatelet therapy advocate a 1 to 12-month dual antiplatelet therapy after bare metal stent PCI and an up to 12-month dual antiplatelet therapy after PCI in patients with ACS and drug-eluting stent PCI. Premature withdrawal of dual antiplatelet therapy carries a substantial risk of stent thrombosis but perioperative continuation of dual antiplatelet therapy is associated with an increased risk of bleeding, particularly in patients treated with the new potent drugs prasugrel and ticagrelor. Based on the various available assays, the lack of validated cut-offs and the disappointing results of targeted antiplatelet therapy as demonstrated by the GRAVITAS trial, current guidelines of international societies recommend platelet function testing only for selected high risk patients despite the known association between clopidogrel low responsiveness and ischemic events. However, for individual patients taking clopidogrel, platelet function monitoring may be considered to safely shorten the preoperative waiting period, to assess the risk of bleeding and transfusion and to initiate specific therapy in bleeding patients.     

Emergency cardiac surgery in patients with acute coronary syndromes: a review of the evidence and perioperative implications of medical and mechanical therapeutics

Patients with acute coronary syndromes who require emergency cardiac surgery present complex management challenges. The early administration of antiplatelet and antithrombotic drugs has improved overall survival for patients with acute myocardial infarction, but to achieve maximal benefit, these drugs are given before coronary anatomy is known and before the decision to perform percutaneous coronary interventions or surgical revascularization has been made. A major bleeding event secondary to these drugs is associated with a high rate of death in medically treated patients with acute coronary syndrome possibly because of subsequent withholding of antiplatelet and antithrombotic therapies that otherwise reduce the rate of death, stroke, or recurrent myocardial infarction. Whether the added risk of bleeding and blood transfusion in cardiac surgical patients receiving such potent antiplatelet or antithrombotic therapy before surgery specifically for acute coronary syndromes affects long-term mortality has not been clearly established. For patients who do proceed to surgery, strategies to minimize bleeding include stopping the anticoagulation therapy and considering platelet and/or coagulation factor transfusion and possibly recombinant-activated factor VIIa administration for refractory bleeding. Mechanical hemodynamic support has emerged as an important option for patients with acute coronary syndromes in cardiogenic shock. For these patients, perioperative considerations include maintaining appropriate anticoagulation, ensuring suitable device flow, and periodically verifying correct device placement. Data supporting the use of these devices are derived from small trials that did not address long-term postoperative outcomes. Future directions of research will seek to optimize the balance between reducing myocardial ischemic risk with antiplatelet and antithrombotics versus the higher rate perioperative bleeding by better risk stratifying surgical candidates and by assessing the effectiveness of newer reversible drugs. The effects of mechanical hemodynamic support on long-term patient outcomes need more stringent analysis.     

Perioperative management of antiplatelet agents

Perioperative management of antiplatelet agents is a common challenge with the increased number of patients requiring long-term therapy following coronary stenting. Debate currently exists regarding if and when to discontinue antiplatelet therapy prior to elective surgery. The delicate balance between decreasing the risk of bleeding intraoperatively and minimizing the risk of stent thrombosis in patients who are already at a high thrombotic risk is a major concern. This article summarizes the information available for perioperative management of common antiplatelet agents, as well as antiplatelet agents in development.     

Perioperatives Management von Patienten mit Koronarstents bei nichtherzchirurgischen Eingriffen

In patients with coronary stents scheduled for surgery the question arises whether and how antiplatelet therapy should be continued. Risks of perioperative bleeding and of acute stent thrombosis have to be considered simultaneously. The bleeding risk depends primarily on the kind of surgery and on patient comorbidity. The risk of stent thrombosis is increased in these patients due to the thrombogenic surface of the stents. The main determinants are hereby the time duration after stent implantation, the kind of the stent [uncoated (bare-metal stent, BMS) or coated (drug-eluting stent, DES)], as well as angiographic and clinical patient factors. Therefore, perioperative antiplatelet therapy has to be individually adapted for each patient. Bridging with heparin is ineffective. Bridging with intravenous antiplatelet drugs during the perioperative interruption of oral antiplatelet therapy might be a potential procedure in high-risk patients. Whether bedside monitoring of antiplatelet therapy improves the perioperative management of these patients and reduces adverse outcome is object of current studies.     

Coronary stents and anaesthesia

The coronary stents are widely used to prevent coronary restenosis after percutaneous coronary intervention. Dual antiplatelet therapy (acetyl salicylic acid and a thienopyridine-clopidogrel or ticlopidine) are prescribed at least during six weeks after conventional stent and six months after drug eluting stent insertion to prevent stent thrombosis. When an invasive procedure is required, a risk of stent thrombosis arises after stopping antiplatelet therapy and a risk of bleeding when continuing this treatment. Therefore, cardiologists should choose carefully the type of coronary stent before insertion and concerned physicians (anaesthesiologists, surgeons, cardiologists) should decide a perioperative strategy in these high-risk patients.     

Coronary stent management in elective genitourinary surgery

What's known on the subject? and What does the study add? Withdrawal of dual antiplatelet therapy before the recommended, 12 months for drug‐eluting stents and 1 month for bare‐metal stents increases the rate of major adverse coronary events and mortality. However, in those undergoing surgery the risk of bleeding is increased substantially for those on antiplatelet agents. Successful management in patients with coronary stents who must undergo elective or non‐elective urological surgery should be a multidisciplinary decision. This article reviews the literature and recommends a protocol for clinical management of patients undergoing urological procedures after coronary stent placement. To review the literature on coronary stents and genitourinary surgery and provide a protocol for perioperative. The keywords, ‘elective surgery’, ‘aspirin’, ‘clopidogrel’, ‘guidelines for percutaneous coronary intervention’, and ‘antiplatelet therapy after coronary stent placement’ were used to search PubMed for any relevant articles relating to coronary stents. Recommendations were made based on the whether the procedures patients were exposed to placed them at low‐, moderate‐ or high‐bleeding risk based on the extent of the procedure. All elective procedures should be delayed for 1 month after bare‐metal stent placement and 1 year after drug‐eluting stent placement. In patients classified as low risk (endoscopy and laser prostatectomy), aspirin should be continued throughout the perioperative period and dual antiplatelet therapy should continue 24–48 h postoperatively, if there is no concern for active bleeding. In those classified as moderate risk (scrotal procedures, transurethral resection of bladder tumours, transurethral resection of the prostate, urinary sphincter placement) dual antiplatelet therapy should be discontinued 5–7 days before the procedure and continued within 7 days after procedure, if there is no concern for active bleeding, in consultation with cardiology. In high‐risk procedures (cystectomy, nephrectomy, prostatectomy, penile prosthesis placement) dual antiplatelet therapy should be discontinued 10 days before the procedure and continued postoperatively within 7–10 days of the procedure, when there is no longer a concern for active bleeding with the assistance of a cardiologist. Coronary artery disease is becoming more prominent in our society, increasing the use of coronary stents and antiplatelet agents. With the proposed protocol, it is safe to proceed with surgical intervention in those that have adequate stent endothelialisation.     

Prospective observational cohort study of the association between antiplatelet therapy,bleeding and thrombosis in patients with coronary stents undergoing noncardiac surgery

Background

The perioperative management of antiplatelet therapy in noncardiac surgery patients who have undergone previous percutaneous coronary intervention (PCI) remains a dilemma. Continuing dual antiplatelet therapy (DAPT) may carry a risk of bleeding, while stopping antiplatelet therapy may increase the risk of perioperative major adverse cardiovascular events (MACE).

Der Patient mit Koronarstent

Nowadays stents are implanted in over 90% of percutaneous coronary interventions. Depending on the type of stent implanted, dual antiplatelet therapy combining a cyclooxygenase inhibitor such as acetylsalicylic acid and an adenosine diphosphate receptor antagonist (thienopyridine) such as clopidogrel is required for 1–12 months. Premature termination of antiplatelet therapy during non-cardiac surgery significantly increases the risk of stent thrombosis and consequently myocardial infarction, whereas continuation of dual antiplatelet therapy during surgery increases the risk of severe bleeding. Accordingly, treatment recommendations have to be based on the individual relative risk. In cases with a high risk for major bleeding during surgery, interruption of antiplatelet therapy may be required, whereas in cases of a high risk of stent thrombosis, both antiplatelet drugs should be continued throughout surgery. Patients on dual antiplatelet therapy should be counseled by a team of anesthesiologists, surgeons and cardiologists, to devise the right point in time for the operation, the best perioperative antiplatelet therapy and the appropriate perioperative monitoring.