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Karotid Endarterektomi Sonrası Kanamada Preoperatif Tekli ve İkili Antiplatelet Tedavinin Karşılaştırılması

Year 2019, Volume: 22 Issue: 3, 205 - 209, 24.12.2019

Abstract

Giriş: Tekli veya ikili antiplatelet tedavi (TAPT veya İAPT), klinik semptomlar ve revaskülarizasyondan bağımsız olarak karotis arter darlığı (KAD) bulunan tüm hastalarda endikedir. Karotis endarterektomi (KEA) uygulanacak hastalarda preoperatif TAPT veya İAPT, cerrahi sırasında ve postoperatif dönemde kanama riskini arttırabilir. Özellikle klopidogrel kullanan hastalarda preoperatif tedavinin kesilmesi konusunda fikir birliği yoktur. Bu sorunun çözümüne katkıda bulunmayı amaçladık.

Hastalar ve Yöntem: Çalışmaya KEA uygulanan 54 hasta alındı ve retrospektif olarak değerlendirildi. Ameliyat öncesinde sadece aspirin içeren TAPT (TAPT grubu, n= 34) ve klopidogrel ile aspirini içeren İAPT (İAPT grubu, n= 20) kullanmış hastalardan iki farklı grup oluşturuldu. Hastalar tekrar eksplorasyon gerektiren perioperatif kanama, drenaj, hematom nedeniyle revizyon, kan ve kan ürünü kullanımı ve diğer komplikasyonlar (miyokart infarktüsü, kraniyal sinir hasarı ve ölüm) açısından değerlendirildi.

Bulgular: Perioperatif kanama ve drenaj miktarları İAPT grubunda 207.5 ± 90.4 mL, TAPT grubunda 177.9 ± 93.9 mL olarak ölçüldü ve gruplar karşılaştırıldığında anlamlı fark gözlenmedi (p= 0.263). İAPT grubundaki bir hasta kanama nedeniyle revize edildi ve TAPT grubundaki bir hasta hematom nedeniyle tekrar ameliyat edildi (p= 0.699). Hiçbir hastada miyokart infarktüsü, kraniyal sinir hasarı ve hastanede kalış süresi boyunca ölüm saptanmadı.

Sonuç: Nörolojik tarafta serebrovasküler olayların önlenmesinde primer olarak kullanılan klopidogrelin, kardiyovasküler cerrahi alanında da KEA planlanan hastalarda operasyon öncesi kesinti yapılmadan devam ettirilmesini öneriyoruz.

References

  • 1. Nicolaides AN, Kakkos SK, Kyriacou E, Griffin M, Sabetai M, Thomas DJ, et al. Asymptomatic internal carotid artery stenosis and cerebrovascular risk stratifi cation. J Vasc Surg 2010;52:1486-96.
  • 2. Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, et al. AHA Guideline: Effectiveness-based Guidelines for the Prevention of Cardiovascular Disease in Women 2011 Update. Circulation 2011;23:1243-62.
  • 3. Engelter S, Lyrer P. Antiplatelet therapy for preventing stroke and other vascular events aft er carotid endarterectomy. Stroke 2004;35:1227-8.
  • 4. Mehta SR, Yusuf S, Peters RJ, Bertrand ME, Lewis BS, Natarajan MK, et al. Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study. Lancet 2001;358:527-33.
  • 5. Steinhubl SR, Berger PB, Mann JT, Fry ET, De Lago A, Wilmer C, et al. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA 2002;288:2411-20.
  • 6. Paciaroni M, Bogousslavsky J. Antithrombotic therapy in carotid artery stenosis: an update. Eur Neurol 2015;73:51-6.
  • 7. Miceli A, Duggan SM, Aresu G, de Siena PM, Romeo F, Glauber M, et al. Combined clopidogrel and aspirin treatment up to surgery increases the risk of postoperative myocardial infarction, blood loss and reoperation for bleeding in patients undergoing coronary artery bypass grafting. Eur J Cardiothorac Surg 2013;43:722-8.
  • 8. Schoenefeld E, Donas KP, Radicke A, Osada N, Austermann M, Torsello G. Preoperative use of aspirin for patients undergoing carotid endarterectomy. Vasa 2012;41:282-7.
  • 9. Stone DH, Goodney PP, Schanzer A, Nolan BW, Adams JE, Powell RJ, et al. Clopidogrel is not associated with major bleeding complications during peripheral arterial surgery. J Vasc Surg 2011;54:779-84.
  • 10. Fares RR, Lansing LS, Gallati CA, Mousa SA. Antiplatelet therapy with clopidogrel and aspirin in vascular diseases: clinical evidence for and against the combination. Expert Opin Pharmacother 2008;9:377-86.
  • 11. Markus HS, Droste DW, Kaps M, Larrue V, Lees KR, Siebler M, et al. Dual antiplatelet therapy with clopidogrel and aspirin in symptomatic carotid stenosis evaluated using doppler embolic signal detection: the clopidogrel and aspirin for reduction of emboli in symptomatic carotid stenosis (CARESS) trial. Circulation 2005;111:2233-40.
  • 12. Payne DA, Jones CI, Hayes PD, Thompson MM, London NJ, Bell PR, et al. Beneficial effects of clopidogrel combined with aspirin in reducing cerebral emboli in patients undergoing carotid endarterectomy. Circulation 2004;109:1476-81.
  • 13. Diener HC, Bogousslavsky J, Brass LM, Cimminiello C, Csiba L, Kaste M, et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomized, double-blind, placebo-controlled trial. Lancet 2004;364:331-7.
  • 14. Çerşit S, Şahin M. Karotis artere stent yerleştirme işleminde tersiyer merkez deneyimi ve kısa dönem sonuçlar. Koşuyolu Heart J 2018;21:93-7.
  • 15. Jackson AJ, Teenan RP, Orr DJ. The use of clopidogrel in carotid endarterectomy: an audit of current practise. Eur J Vasc Endovasc Surg 2007;34:312-3.
  • 16. Fox KA, Mehta SR, Peters R, Zhao F, Lakkis N, Gersh BJ, et al. Clopidogrel in unstable angina to prevent recurrent ischaemic events trial. Benefits and risks of the combination of clopidogrel and aspirin in patients undergoing surgical revascularization for non-STelevation acute coronary syndrome: the Clopidogrel in Unstable angina to prevent Recurrent ischaemic Events (CURE) Trial. Circulation 2004;110:1202-8.
  • 17. Baracchini C, Gruppo M, Mazzalai F, Lorenzetti R, Meneghetti G, Ballotta E. Predictors of neck bleeding after eversion carotid endarterectomy. J Vacs Surg 2011;54:699-705.
  • 18. Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011;124:2610-42.
  • 19. Gisbert SMM, Almonacil VAS, Garcia JMZ, Gascó BC, Palonés FJG, Monzón EO. Predictors of cervical bleeding after carotid endarterectomy. Ann Vasc Surg 2014;28:366-74.
  • 20. Mazzalai F, Piatto G, Toniato A, Lorenzetti R, Baracchini C, Ballotta E. Using protamine can significantly reduce the incidence, of bleeding complications after carotid endarterectomy without increasing the risk of ischemic cerebral events. World J Surg 2014;38:1227-32.

Comparison of Preoperative Single and Dual Antiplatelet Therapy in Bleeding After Carotid Endarterectomy

Year 2019, Volume: 22 Issue: 3, 205 - 209, 24.12.2019

Abstract

Introduction: Single or dual antiplatelet therapy (SAPT or DAPT) is indicated in all patients with carotid artery stenosis (CAS), irrespective of clinical symptoms and revascularisation. In patients with carotid endarterectomy (CEA), SAPT or DAPT preoperatively may increase the risk of bleeding during surgery and postoperative period. There is no consensus regarding the discontinuation of preoperative treatment, especially in patients using clopidogrel. Our goal was to find the solution to this problem.

Patients and Methods: A total of 54 patients undergoing CEA were included in the study and evaluated retrospectively. Two different groups were formed: patients who used aspirin only in the preoperative treatment, containing SAPT (SAPT group, n= 34), and aspirin with clopidogrel, containing DAPT (DAPT group, n= 20). The patients were evaluated for perioperative bleeding, which needed re-exploration, drainage, revision due to haematoma, blood and blood-product change, or included other complications.

Results: Perioperative bleeding and drainage amounts were measured as 207.5 ± 90.4 cc in the DAPT group and 177.9 ± 93.9 cc in the SAPT group, and no significant difference was observed when the groups were compared (p= 0.263). One patient in the DAPT group was revised because of haemorrhage, and one patient in the SAPT group was re-operated due to haematoma (p= 0.699). No patients were found to have suffered myocardial infraction, cranial nerve damage, or death during hospital stay.

Conclusion: We recommend that clopidogrel in the prevention of cerebrovascular events in neurology should be primarily continued in the cardiovascular surgery without any interruption in patients with CEA.

References

  • 1. Nicolaides AN, Kakkos SK, Kyriacou E, Griffin M, Sabetai M, Thomas DJ, et al. Asymptomatic internal carotid artery stenosis and cerebrovascular risk stratifi cation. J Vasc Surg 2010;52:1486-96.
  • 2. Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, et al. AHA Guideline: Effectiveness-based Guidelines for the Prevention of Cardiovascular Disease in Women 2011 Update. Circulation 2011;23:1243-62.
  • 3. Engelter S, Lyrer P. Antiplatelet therapy for preventing stroke and other vascular events aft er carotid endarterectomy. Stroke 2004;35:1227-8.
  • 4. Mehta SR, Yusuf S, Peters RJ, Bertrand ME, Lewis BS, Natarajan MK, et al. Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study. Lancet 2001;358:527-33.
  • 5. Steinhubl SR, Berger PB, Mann JT, Fry ET, De Lago A, Wilmer C, et al. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA 2002;288:2411-20.
  • 6. Paciaroni M, Bogousslavsky J. Antithrombotic therapy in carotid artery stenosis: an update. Eur Neurol 2015;73:51-6.
  • 7. Miceli A, Duggan SM, Aresu G, de Siena PM, Romeo F, Glauber M, et al. Combined clopidogrel and aspirin treatment up to surgery increases the risk of postoperative myocardial infarction, blood loss and reoperation for bleeding in patients undergoing coronary artery bypass grafting. Eur J Cardiothorac Surg 2013;43:722-8.
  • 8. Schoenefeld E, Donas KP, Radicke A, Osada N, Austermann M, Torsello G. Preoperative use of aspirin for patients undergoing carotid endarterectomy. Vasa 2012;41:282-7.
  • 9. Stone DH, Goodney PP, Schanzer A, Nolan BW, Adams JE, Powell RJ, et al. Clopidogrel is not associated with major bleeding complications during peripheral arterial surgery. J Vasc Surg 2011;54:779-84.
  • 10. Fares RR, Lansing LS, Gallati CA, Mousa SA. Antiplatelet therapy with clopidogrel and aspirin in vascular diseases: clinical evidence for and against the combination. Expert Opin Pharmacother 2008;9:377-86.
  • 11. Markus HS, Droste DW, Kaps M, Larrue V, Lees KR, Siebler M, et al. Dual antiplatelet therapy with clopidogrel and aspirin in symptomatic carotid stenosis evaluated using doppler embolic signal detection: the clopidogrel and aspirin for reduction of emboli in symptomatic carotid stenosis (CARESS) trial. Circulation 2005;111:2233-40.
  • 12. Payne DA, Jones CI, Hayes PD, Thompson MM, London NJ, Bell PR, et al. Beneficial effects of clopidogrel combined with aspirin in reducing cerebral emboli in patients undergoing carotid endarterectomy. Circulation 2004;109:1476-81.
  • 13. Diener HC, Bogousslavsky J, Brass LM, Cimminiello C, Csiba L, Kaste M, et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomized, double-blind, placebo-controlled trial. Lancet 2004;364:331-7.
  • 14. Çerşit S, Şahin M. Karotis artere stent yerleştirme işleminde tersiyer merkez deneyimi ve kısa dönem sonuçlar. Koşuyolu Heart J 2018;21:93-7.
  • 15. Jackson AJ, Teenan RP, Orr DJ. The use of clopidogrel in carotid endarterectomy: an audit of current practise. Eur J Vasc Endovasc Surg 2007;34:312-3.
  • 16. Fox KA, Mehta SR, Peters R, Zhao F, Lakkis N, Gersh BJ, et al. Clopidogrel in unstable angina to prevent recurrent ischaemic events trial. Benefits and risks of the combination of clopidogrel and aspirin in patients undergoing surgical revascularization for non-STelevation acute coronary syndrome: the Clopidogrel in Unstable angina to prevent Recurrent ischaemic Events (CURE) Trial. Circulation 2004;110:1202-8.
  • 17. Baracchini C, Gruppo M, Mazzalai F, Lorenzetti R, Meneghetti G, Ballotta E. Predictors of neck bleeding after eversion carotid endarterectomy. J Vacs Surg 2011;54:699-705.
  • 18. Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011;124:2610-42.
  • 19. Gisbert SMM, Almonacil VAS, Garcia JMZ, Gascó BC, Palonés FJG, Monzón EO. Predictors of cervical bleeding after carotid endarterectomy. Ann Vasc Surg 2014;28:366-74.
  • 20. Mazzalai F, Piatto G, Toniato A, Lorenzetti R, Baracchini C, Ballotta E. Using protamine can significantly reduce the incidence, of bleeding complications after carotid endarterectomy without increasing the risk of ischemic cerebral events. World J Surg 2014;38:1227-32.
There are 20 citations in total.

Details

Primary Language English
Subjects Clinical Sciences
Journal Section Original Investigations
Authors

Özden Vezir This is me 0000-0001-9948-0515

Esra Ertürk 0000-0001-8335-5832

Publication Date December 24, 2019
Published in Issue Year 2019 Volume: 22 Issue: 3

Cite

Vancouver Vezir Ö, Ertürk E. Comparison of Preoperative Single and Dual Antiplatelet Therapy in Bleeding After Carotid Endarterectomy. Koşuyolu Heart Journal. 2019;22(3):205-9.