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Published on: March 15, 2022
[Urgent or emergent coronary revascularization using bilateral internal thoracic artery after previous clopidogrel
F Schmidtler1, B Gansera, K Spiliopoulos
1Krankenhaus München-Bogenhausen, Abteilung für Kardiovaskularchirurgie, Englschalkingerstr. 77, 81925 München, Germany.
Insights
Clopidogrel use before urgent coronary artery bypass grafting (CABG) increases bleeding complications, including higher chest tube output and reexploration rates. However, using bilateral internal thoracic arteries (ITAs) in these patients is feasible with manageable bleeding risks.
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Pharmacology
Background:
- Clopidogrel is standard for preventing stent thrombosis after percutaneous coronary interventions.
- Its irreversible platelet inhibition poses bleeding risks if urgent coronary artery bypass grafting (CABG) is needed.
- This study assesses bleeding complications in urgent CABG patients receiving clopidogrel.
Purpose of the Study:
- To evaluate the impact of pre-operative clopidogrel on bleeding complications during urgent CABG.
- To compare outcomes between patients who received clopidogrel and those who did not.
Main Methods:
- Retrospective analysis of 166 patients undergoing urgent/emergency CABG using bilateral internal thoracic arteries (ITAs) and saphenous veins.
- Comparison of 83 patients with recent clopidogrel/aspirin use versus 83 patients without.
- Evaluation of chest tube output, reexploration rates, blood product transfusion, ventilation time, and ICU stay.
Main Results:
- The clopidogrel group showed significantly higher 24-hour chest tube output (935 vs. 754 ml, p=0.018).
- Reexploration rates were higher in the clopidogrel group (7.2% vs. 0%, p<0.001).
- Increased transfusion of red cells, platelets, and fresh frozen plasma was observed in the clopidogrel group.
Conclusions:
- Pre-operative clopidogrel significantly increases bleeding complications in urgent CABG, notably chest tube output and reexploration.
- Higher transfusion requirements, especially for platelets, are associated with clopidogrel use.
- Routine use of bilateral ITAs in patients with recent clopidogrel exposure is possible despite increased bleeding risks.
Background:
Application of clopidogrel before diagnostic or therapeutical percutaneous coronary interventions has become standard for stent-thrombosis prevention. The irreversible platelet inhibition causes increasing bleeding complications if urgent coronary artery bypass grafting becomes necessary. This study evaluates the effect on bleeding complications of clopidogrel in urgent CABG using bilateral internal thoracic artery (ITA) and saphenous veins in all patients.
Methods:
We retrospectively analyzed 166 patients (operated between 1/00-12/02) with urgent or emergency CABG, using both ITAs and compared 83 patients with previous (within 5 days) clopidogrel and aspirin application to 83 patients without clopidogrel. We evaluated chest tube output, reexploration rate and necessity of blood products, ventilation time and ICU stay.
Results:
Both groups were comparable with age, gender, number of performed anastomoses (mean 4/ patient). Chest tube output (24 h) was higher in the clopidogrel group (935 +/- 599 ml vs 754 +/- 335 ml (p = 0.018)), as well as reexploration rate with 7.2% (6 of 83) vs 0% (0 of 83) (p < 0.001). Number of blood products in the clopidogrel group for red cells was 2.41 +/- 1.88 U vs 1.84 +/- 1.47 U p = 0.03, for plateletes 0.43 +/- 0.88 U vs 0.024 +/- 0.22 p = 0.0001, for fresh frozen plasma 0.41 +/- 1.14 U vs 0.096 +/- 0.59 U p = 0.029. Mechanical ventilation time was 11.35 +/- 8.77 h vs 10.57 +/- 9.12 h p = 0.51, ICU stay 32.1 +/- 21.8 h vs. 29.8 +/- 21.1 h (p = 0.48).
Conclusions:
Previous application of clopidogrel in combination with aspirin before urgent CABG induces increased chest tube output, reexploration rate and necessity of blood products, especially of plateletes. Nevertheless, routine use of both ITAs in patients after clopidogrel exposure can be performed with acceptable bleeding complications.
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