A case of myocardial infarction caused by obstruction of a drug-eluting stent during the perioperative period.

Hiroaki Toyama,Masanori Yamauchi,Yutaka Ejima,Kazutomo Saito,Takanori Aihara,Hiroyuki Anzai,Naoya Kobayashi

doi:10.1186/s40981-015-0025-2

Hiroaki Toyama, Masanori Yamauchi + Show 5 more

Open Access

https://doi.org/10.1186/s40981-015-0025-2

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Abstract

We report a patient who developed drug-eluting stent (DES) thrombosis induced by discontinuation of dual antiplatelet therapy (DAPT) and subsequently had a massive surgical site bleed caused by restarting heparin and DAPT during the perioperative period.An 85-year-old man visited a local hospital owing to complaints dyspnea. He was diagnosed with laryngeal cancer and was scheduled for a total laryngectomy. Preoperative examinations showed an anteroseptal myocardial infarction. A DES was placed at segment 6 of the coronary artery and DAPT was initiated 27 days before surgery. After admission to our hospital, DAPT was replaced with unfractionated heparin. On the operation day, heparin was discontinued, and a tracheotomy, total laryngectomy and right hemi-thyroidectomy were performed. While recovering from anesthesia, ischemic ST elevation appeared. Cardiac catheterization revealed complete obstruction of the DES by a white thrombus. After recanalization, heparin and DAPT were restarted, and bleeding occurred. The next day, total blood loss was 2755 mL and surgical hemostasis was performed.Because his serum creatine kinase value was elevated at the cessation of heparin, anticoagulation by unfractionated heparin could not have prevented platelet thrombosis. Therefore, we should performed the tracheostomy to secure the patient’s airway under DAPT or only aspirin therapy a month after the DES implantation, and performed the laryngectomy and right hemi-thyroidectomy five months after the first surgery. This case is serious warnings of perioperative major adverse cardiac events induced by discontinuation of DAPT; unfractionated heparin was an insufficient safeguard against platelet thrombosis, and perioperative massive bleeding induced by restarting antiplatelet and anticoagulation therapy. In addition, a series of human errors, which the cardiologist chosen DES regardless of scheduled total larygectomy, the discontinuation of antiplatelet therapy shortly after a DES placement, and the surgical staffs failed to share the elevated serum CK and CK-MB values, caused life-threatening complications.

Highlights

Obstruction of a drug eluting stent (DES) during the perioperative period is a possible and potentially lethal complication of the procedure
The serum creatine kinase (CK)-MB value of the patient was elevated at the time of cessation of heparin despite a slightly prolonged activated partial thromboplastin time (aPTT) (Table 1)
Because the patient had been placed a DES, we should have first performed the tracheostomy on the patient with strict hemostasis to secure the airway under continuation of dual antiplatelet therapy (DAPT) or only aspirin a month after the DES implantation

Summary

Background

Obstruction of a drug eluting stent (DES) during the perioperative period is a possible and potentially lethal complication of the procedure. On 27 days before the laryngectomy, the cardiologist at the local hospital placed a DES at segment 6 (#6) of the anterior descending coronary artery and initiated DAPT, including 100 mg of aspirin and 75 mg of clopidogrel, despite the cardiologist recognized the patient was scheduled laryngectomy. He was admitted to our hospital 10 days before the laryngectomy. The patient entered the operating room in a wheelchair He showed no significant changes in 3-lead electrocardiogram and did not complain of a chest pain.

POD 2 POD 5 POD 6 POD before surgery surgery Morning Evening

Discussion

Conclusion