2024 FSA Podium and Poster Abstracts

S011: PERIOPERATIVE CANGRELOR IN A PATIENT UNDERGOING EMERGENT NON-CARDIAC SURGERY AFTER RECENT CARDIAC STENT PLACEMENT
Rhiya Mittal, BS; Aisha Khan, MD, MPH; Richard Zack-Guasp, MD; Leidi Paez, PharmD; Jackson Memorial Hospital Department of Anesthesiology, University of Miami Miller School of Medicine

Introduction: Dual antiplatelet therapy (DAPT) with aspirin and a P2Y₁₂ inhibitor is the gold standard for the prevention of thrombotic complications in patients who have undergone percutaneous coronary intervention (PCI) with stent placement. Cangrelor infusion has emerged as a more reliable, prompt, and potent alternative for prevention of periprocedural myocardial infarction, specifically during PCIs. This medication is short acting, rapidly reversible, and is typically stopped shortly after completion of the PCI and transitioned to an oral P2Y₁₂ inhibitor. Off-label use of Cangrelor as bridging therapy prior to cardiac surgery has been documented, yet there’s no data supporting its use perioperatively for non-cardiac surgery.

Methods: We present the case of a 65-year-old male who presented to the ED following a weeklong history of difficulty urinating, right flank pain, and progressive painless gross hematuria. Following Urology consultation, the patient was scheduled for emergent TURBT in the setting of presumed bladder tumor. Of note, the patient had a recent STEMI and underwent PCI with DES placement 13 days prior to the Urological procedure.

Results: In the case of our 65-year-old male, the patient was started on DAPT following PCI 13 days prior to presentation. Given the need for emergent TURBT, cardiology was consulted for perioperative management of DAPT in the setting of recent DES placement. Patient was given his dose of Plavix and was to start on IV Cangrelor at a rate of 0.75mcg/kg/min 24 hours after his last oral dose, with plan to restart Plavix postoperatively (Figure 1). Patient required multiple blood transfusions throughout his hospital stay and one prophylactic transfusion intraoperatively. TEG was used intraoperatively to assess degree of platelet inhibition. Patient remained hemodynamically stable perioperatively, and subsequently was transitioned off Cangrelor without further events during this hospital stay. Unfortunately, the patient did have a repeat event several days after discharge and faced sudden death from hemorrhagic shock.

Discussion: Given this patient’s recent history of PCI and DES placement, complete preoperative DAPT discontinuation would pose significant risks for thrombotic events and possible stent occlusion. Considering this patient’s symptomatic hematuria leading to an acute drop in hemoglobin, surgery was unable to be deferred, necessitating a safe method of platelet inhibition which would allow to both prevent thrombosis and minimize perioperative bleeding. Currently, Cangrelor is the only available intravenous antiplatelet agent with a short half-life (60min.) and no renal dosing requirement, making it a suitable option for bridging therapy in high-risk patients on DAPT. A study in which Cangrelor was started three days before surgery, discontinued 6.6±1.5hr before surgery, and restarted 9±6hr after surgery, showed no ischemic events up to 30 days postoperatively and a mean hemoglobin drop <2g/dL. Additionally, patients with coronary stents who undergo procedures requiring preoperative P2Y₁₂ discontinuation, should continue aspirin peri-procedurally, if possible, and the P2Y₁₂ inhibitor should be initiated as soon as possible postoperatively.

Figure 1. Patient hospital course and perioperative cangrelor and DAPT management.