Key result
Peri-operative cangrelor bridging in stented patients shows no major ischemic events or fatal bleeding.
Why the study?
Perioperative management of DAPT after PCI in patients at high thrombotic risk undergoing non-deferrable surgery is poorly defined, and data on cangrelor bridging are scant.
Does a bridging protocol with cangrelor prevent ischemic events without excessive bleeding in high thrombotic risk patients with previous PCI undergoing non-deferrable surgery?
Observational (n=18)
Yes
Does a bridging protocol with cangrelor prevent ischemic events without excessive bleeding in high thrombotic risk patients with previous PCI undergoing non-deferrable surgery?
A bridging protocol with cangrelor appears feasible and safe for patients with recent PCI requiring DAPT interruption for non-deferrable surgery, with no major ischemic events observed in a small cohort.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Real-world data demonstrate substantial variability in cangrelor dosing among patients receiving antiplatelet therapy as a bridging strategy prior to surgery. There is a suggestion that dosing patterns may affect outcomes. These findings highlight the need for further research and continued evaluation of dosing patterns and clinical outcomes to improve decision-making in patients requiring bridging intravenous antiplatelet therapy following PCI.”
“The present study confirms that there's a lot of confusion surrounding the optimal dosing of cangrelor in patients requiring surgery after PCI.”
“A challenge for physicians is that unlike the PCI dose of cangrelor, which is FDA approved based on CHAMPION PHOENIX, the bridging dose of cangrelor is not FDA approved. So there is less guidance for physicians, and unstudied dosing is more common in the setting of bridging.”
May support cangrelor bridging in high-risk stented patients needing urgent surgery; leaves open confirmation in larger prospective studies.
Background Perioperative management of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) in patients deemed at high thrombotic risk undergoing non-deferrable surgery remains poorly defined. Cangrelor represents a potential treatment option as a “bridge” from discontinuation of oral P2Y12 receptor antagonists to surgical procedures, but data in this setting are still scant. Purpose We sought to describe a real-world experience of a bridging protocol using cangrelor for patients referred to relevant bleeding risk surgery requiring withdrawal of DAPT. Methods We collected data from 7 Italian centers on patients with previous PCI, still on DAPT, undergoing non-deferrable surgery which required discontinuation of one or both antiplatelet agents. A standardized bridging protocol using cangrelor infusion before and eventually after surgery was applied (Figure 1). Results Between December 2017 and January 2019, a total of 18 patients (mean age 70±10 years; male 85%) were enrolled. In the majority (89%) of patients, the index PCI was performed due to acute coronary syndrome (ACS) and 2±1.7 stents per patient were implanted. All patients required non-deferrable, intermediate-high bleeding risk surgery as pulmonary lobectomy, colectomy, endoscopic bladder surgery, paranasal sinus surgery, coronary artery by-pass surgery and valvular repair, hip replacement, endoscopy sphincterotomy. High thrombotic risk categories included PCI time <1 month, SCA time <3 months, stent failure occurrence, previous Absorb BVS implantation. Due to the surgical bleeding risk, discontinuation of P2Y12 inhibitor was required 5 days before surgery (ticagrelor, n=13; prasugrel=1; clopidogrel, n=5). All patients but 1 maintained aspirin through the perioperative phase. Cangrelor infusion was started at a bridging dose (0.75 mcg/kg/min) 3 days before planned surgery and was discontinued 6.9±1.5 hours before. After surgery, drainages were left in all patients but 3. In 56% of patients, cangrelor was resumed within 24 hours from surgery (mean time 9±7 hours) for a mean of 36±38 hours. Drainages were removed after discontinuation of cangrelor, in order to reduce bleeding complications. Within 2 hours from post-operative cangrelor discontinuation, a 300 mg clopidogrel loading dose was administered. No major ischemic adverse outcomes occurred during hospital stay and up to 30 days follow-up. The mean Hb drop was 2±1.8 g/dl, 7 patients received blood transfusions consistent with the type of surgeries and no life-threatening or fatal bleeding occurred. Figure 1. Standardized bridging protocol. Conclusions Peri-operative bridge therapy with cangrelor is a feasible approach for stented patients at high thrombotic risk referred to non-deferrable surgery requiring DAPT discontinuation. Larger studies are warranted to support the safety of this strategy.
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Rossini et al. (2019) conducted an observational in Previous PCI on DAPT undergoing non-deferrable surgery (n=18). Cangrelor bridging protocol was evaluated on Major ischemic adverse outcomes up to 30 days. A peri-operative bridging protocol with cangrelor in 18 stented patients undergoing non-deferrable surgery resulted in no major ischemic adverse outcomes at 30 days and no fatal bleeding.
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