Use of Cangrelor during Venoarterial Extracorporeal Membrane Oxygenation Following Percutaneous Coronary Intervention

Abstract

Purpose In patients undergoing percutaneous coronary intervention (PCI) complicated by cardiogenic shock, venoarterial extracorporeal membrane oxygenation (VA-ECMO) is used as a bridge to surgery, ventricular assist device (VAD), or recovery. Bleeding and thrombotic complications afflict patients on VA-ECMO support. Cangrelor is an ideal agent to use as part of dual antiplatelet therapy after PCI due to its short half-life, however there are no data regarding the use of cangrelor in the setting of VA-ECMO. Methods This was a single-center retrospective case series of patients who received cangrelor while on VA-ECMO following PCI from January 1, 2016 through August 31, 2018. The objective of this case series was to describe the complications and outcomes associated with the use of cangrelor during VA-ECMO. Results Thirteen patients were included (median age of 61 years). Past medical history included hyperlipidemia (69%), type 2 diabetes mellitus (62%), and hypertension (46%). Forty-six percent of patients presented with a ST-segment elevation myocardial infarction (STEMI), 31% with a NSTEMI, and 23% were elective PCI. Nearly all patients (92%) received a drug-eluting stent and 48% were placed in the LAD. Eighty-five percent of patients received VA-ECMO combined with an Impella for LV venting. Patients were on VA-ECMO for a median of eight days (IQR 6 - 11) and cangrelor for a median of five days (IQR 3 - 8). The dose of cangrelor in all cases was 0.75 mcg/kg/min. Only one patient experienced a thrombotic event (deep vein thrombosis), however 77% patients had a hemorrhagic complication (Figure) and received a median of three units of PRBCs while on cangrelor and VA-ECMO. Fifty-four percent of patients were bridge to recovery, 38% of patients died, and 8% were bridge to ventricular assist device. Conclusion Hemorrhagic complications were frequent in this case series of patients who received cangrelor while on VA-ECMO following PCI, and no repeat coronary events were observed.