Perioperative Aspirin Use Research Articles

To be or not to be on: aspirin and coronary artery bypass graft surgery.

Aspirin's role in secondary prevention for patients with known coronary artery disease (CAD) is well established, validated by numerous landmark trials over the past several decades. However, its perioperative use in coronary artery bypass graft (CABG) surgery remains contentious due to the delicate balance between the risks of thrombosis and bleeding. While continuation of aspirin in patients undergoing CABG following acute coronary syndrome is widely supported due to the high risk of re-infarction, the evidence is less definitive for elective CABG procedures. The literature indicates a significant benefit of aspirin in reducing cardiovascular events in CAD patients, yet its impact on perioperative outcomes in CABG surgery is less clear. Some studies suggest increased bleeding risks without substantial improvement in cardiac outcomes. Specific to elective CABG, evidence is mixed, with some data indicating no significant difference in thrombotic or bleeding complications whether aspirin is continued or withheld preoperatively. Advancements in pharmacological therapies and perioperative care have evolved significantly since the initial aspirin trials, raising questions about the contemporary relevance of earlier findings. Individualized patient assessments and the development of risk stratification tools are needed to optimize perioperative aspirin use in CABG surgery. Further research is essential to establish clearer guidelines and improve patient outcomes. The objective of this review is to critically evaluate the existing evidence into the optimal management of perioperative aspirin in elective CABG patients.

Perioperative aspirin and coronary artery bypass graft surgery: a meta-analysis of randomised controlled trials

Abstract Background Although consensus guidelines demonstrate clear benefit for the continuation of aspirin in patients awaiting coronary artery bypass grafting (CABG) following an acute coronary syndrome where risk of re-infarction outweighs bleeding risk, the evidence remains unclear in the case of elective CABG. We performed the largest to date systematic review and meta-analysis to compare outcomes between CABG patients who stopped and continued aspirin perioperatively. Methods A thorough search of PubMed, MEDLINE and CENTRAL databases was conducted to 25th July 2022 for randomized control trials that evaluated patients undergoing CABG. Summary odds ratios were calculated using a random effects model for dichotomous and continuous variables. Subgroup and sensitivity analyses were conducted in order to explore sources of heterogeneity. Results 16 eligible studies were included with a total of 6188 patients who underwent CABG. Patients who continued Aspirin perioperatively demonstrated an increased risk of all cause mortality [OR 1.37 (0.81-2.33)] and reduced risk of perioperative myocardial infarction [OR 0.81 (0.55-1.18)], however neither were statistically significant. No significant difference was observed between low-dose and higher doses of Aspirin. There was minimal heterogeneity amongst included studies (i2 = 0%, p=0.97 and i2=33%, p=0.13 respectively). Continuing aspirin produced a modest increase in postoperative blood loss [mean difference 66.12mL (-1.45-133.69)], as was a dose greater than 100mg [216.87(-152.99-586.72), p=0.60], however this was not statistically significant. Conclusion Continuing Aspirin before CABG is not associated with a significantly increased risk of all-cause mortality, of perioperative myocardial infarction, and of postoperative bleeding. Future trials with more robust methodology should be aimed at further evaluating this patient cohort to guide perioperative Aspirin use.

The safety of continued low dose aspirin therapy during Complete Supine Percutaneous Nephrolithotomy (csPCNL)

Using anticoagulants and antiplatelet drugs in patients with cardiovascular and medical comorbidities is prevalent. Because of hyper vascular nature of kidney, physicians tend to stop using aspirin before percutaneous nephrolithotomy (PCNL). We have shown the effects of remaining on low dose aspirin in complete supine PCNL (csPCNL). The records of 643 patients who underwent csPCNL between 2012 and 2018 were analyzed. Surgical outcomes and complications of patients who were on aspirin therapy and continued it daily (group A) were compared with those not taking aspirin (group B). Of the 643 csPCNLs, 40 (6%) were performed in patients of group A and the rest of 603 (94%) cases were in group B. The differences between the mean age of groups were statistically significant (60.08±9.45, group A and 48.66±12.32, group B) (P<0.001). Thirty-nine (97.5%) of patients in group A and 548 (90.9%) of group B were stone free by the end of the study which was not statistically significant (P=0.118). The mean operative time between groups A and B (43.20±21.37 and 44.83±16.83, respectively) was not considered significant (P=0.561). There was also no significant difference between 2 groups in any types of complications. Multivariate analysis showed that, perioperative aspirin use was not a significant predictor of transfusion, Hb drop, operative time and other complications. Remaining on aspirin does not increase the risk of bleeding, transfusionand other complications. Consequently, continuing aspirin prioperatively in csPCNL appears safe. There is no fear for continuing aspirin in csPCNL.

Safety of Continuous Low-Dose Aspirin Therapy for Cervical Laminoplasty.

Introduction More spinal surgeries are being performed in patients taking low-dose aspirin for primary and secondary prevention of cardiovascular and cerebrovascular ischemic disease. However, there are no recommended guidelines for perioperative aspirin use in patients undergoing spinal surgery. This study evaluated the perioperative effect of continued low-dose aspirin on cervical laminoplasty. Methods This was a single-institute retrospective study of patients who underwent laminoplasty at the C2/3 to C7/T1 levels for cervical compression lesions. The comparison of 73 patients who continued to take aspirin at 100 mg/day during the perioperative period and 322 patients who took no antiplatelet or anticoagulant drugs examined their patient characteristics, perioperative parameters, and perioperative complications. Results A significantly higher proportion of patients with aspirin were men, and the mean age was significantly higher in patients with than without aspirin (P=0.011 and P<0.001, respectively). The preoperative hemoglobin level was significantly lower in patients with than without aspirin (P=0.033). The number of disk decompression levels, surgical time, intraoperative blood loss, and postoperative drainage volume were not significantly different between patients with and without aspirin. Reoperation for epidural hematoma formation was also not significantly different between patients with and without aspirin. Perioperative blood transfusions were performed in 1 of 73 patients with aspirin and 0 of 322 patients without aspirin, with no significant difference (P=0.185). No cardiovascular or cerebrovascular ischemic events occurred in either group. Conclusions Continuing low-dose aspirin therapy during a perioperative period for cervical laminoplasty did not increase perioperative bleeding or the risk of bleeding-related complications. Therefore, continuing low-dose aspirin may be acceptable for patients undergoing cervical laminoplasty to prevent increased risk of cardiovascular and cerebrovascular accidents due to aspirin withdrawal.

Editorial Comment.

No AccessJournal of UrologyAdult Urology1 Feb 2022Editorial CommentThis article comments on the following:Perioperative Aspirin Use Is Associated with Bleeding Complications during Robotic Partial Nephrectomy Martin Hofmann, Tarik Benidir, and Christopher J. Weight Martin HofmannMartin Hofmann Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio More articles by this author , Tarik BenidirTarik Benidir Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio More articles by this author , and Christopher J. WeightChristopher J. Weight Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002240.01AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, 207(2), p. 283

Continuous Perioperative use of Aspirin as Single Therapy during Percutaneous Nephrolithotomy

Introduction: The rates of heart disease and nephrolithiasis continue to increase in the United States, and aspirin is increasingly prescribed for varying indications. Current recommendations in the urologic literature are to stop aspirin before percutaneous nephrolithotomy (PCNL); however, this is based on expert opinion. This study aims to determine the safety of PCNL performed on patients who took aspirin in the perioperative period. Methods: This study was a retrospective review of 27 consecutive PCNLs for patients who took aspirin in the perioperative period (January 2013-September 2016). Pre- and postoperative hemoglobin was recorded, as were age, sex, BMI, operative duration, skin-to-stone distance, stone size, aspirin dose, aspirin indication, number of blood transfusions, and Clavien-Dindo complication classification. Correlations between hemoglobin and explanatory variables were then explored with linear regression and the Wilcoxon rank-sum test. Results: Of the 199 PCNLs performed, 27 procedures on 23 patients were conducted without discontinuing aspirin perioperatively. Coronary artery disease was the most common indication for aspirin use (81%). Patients experienced a median hemoglobin decline of 1.4 g/dl perioperatively. No significant associations were found between hemoglobin decline and age, sex, BMI, operative duration, skin-to-stone distance, or stone size. There were no Clavien-Dindo grade III or higher complications, and no patients required a blood transfusion or angio-embolization. There were no thrombo-embolic or cardiac events in our series. Conclusions: In our single-center experience, PCNLs performed on patients taking aspirin perioperatively were not associated with the need for blood transfusion nor the occurrence of high-grade complications.

Association of Aspirin Use With Postoperative Hematoma and Bleeding Complications in Foot and Ankle Surgery: A Retrospective Study

Discontinuation of nonsteroidal antiinflammatory drugs 3 to 5 days before elective or nonelective foot and ankle surgery has been recommended, as its continued use during the perioperative period may result in complications; however, data supporting this are limited. In this study, we evaluated the incidence of postoperative bleeding, hematoma formation, and wound dehiscence after perioperative aspirin ingestion before foot and ankle surgery. The medical records of 379 patients treated over a 3-year period were reviewed. Patient demographics, surgical procedures, affected limbs (right foot versus left foot), anatomical surgical sites (forefoot, midfoot, and rearfoot), and week 2 surgical site inspection data were recorded. Mean patient age was 60.12 (range 21 to 81) years, and the overall wound complication rate was 0.80%. The patients were classified into 2 groups: those who took 81 mg of aspirin preoperatively (n = 238, 62.80%) and those who did not (n = 141, 37.20%). Of the 3 patients who developed postoperative bleeding complications, 2 were taking aspirin and 1 was not. Patients taking aspirin had similar wound complication and healing rates as those not taking aspirin. Postoperative hematomas were evacuated in the clinic under sterile conditions and healed by secondary intention. Perioperative aspirin use appears to be safe and effective in foot and ankle surgery, and patients taking aspirin had good surgical outcomes with minimal postoperative complications.

Effect of perioperative aspirin use on hemorrhagic complications in elective craniotomy for brain tumors: results of a single-center, retrospective cohort study.

In daily practice, neurosurgeons face increasing numbers of patients using aspirin (acetylsalicylic acid, ASA). While many of these patients discontinue ASA 7-10 days prior to elective intracranial surgery, there are limited data to support whether or not perioperative ASA use heightens the risk of hemorrhagic complications. In this study the authors retrospectively evaluated the safety of perioperative ASA use in patients undergoing craniotomy for brain tumors in the largest elective cranial surgery cohort reported to date. The authors retrospectively analyzed the medical records of 1291 patients who underwent elective intracranial tumor surgery by a single surgeon from 2007 to 2017. The patients were divided into three groups based on their perioperative ASA status: 1) group 1, no ASA; 2) group 2, stopped ASA (low cardiovascular risk); and 3) group 3, continued ASA (high cardiovascular risk). Data collected included demographic information, perioperative ASA status, tumor characteristics, extent of resection (EOR), operative blood loss, any hemorrhagic and thromboembolic complications, and any other complications. A total of 1291 patients underwent 1346 operations. The no-ASA group included 1068 patients (1112 operations), the stopped-ASA group had 104 patients (108 operations), and the continued-ASA group had 119 patients (126 operations). The no-ASA patients were significantly younger (mean age 53.3 years) than those in the stopped- and continued-ASA groups (mean 64.8 and 64.0 years, respectively; p < 0.001). Sex distribution was similar across all groups (p = 0.272). Tumor locations and pathologies were also similar across the groups, except for deep tumors and schwannomas that were relatively less frequent in the continued-ASA group. There were no differences in the EOR between groups. Operative blood loss was not significantly different between the stopped- (186 ml) and continued- (220 ml) ASA groups (p = 0.183). Most importantly, neither hemorrhagic (0.6%, 0.9%, and 0.8%, respectively; p = 0.921) nor thromboembolic (1.3%, 1.9%, and 0.8%; p = 0.779) complication rates were significantly different between the groups, respectively. In addition, the multivariate model revealed no statistically significant predictor of hemorrhagic complications, whereas male sex (odds ratio [OR] 5.9, 95% confidence interval [CI] 1.7-20.5, p = 0.005) and deep-extraaxial-benign ("skull base") tumors (OR 3.6, 95% CI 1.3-9.7, p = 0.011) were found to be independent predictors of thromboembolic complications. In this cohort, perioperative ASA use was not associated with the increased rate of hemorrhagic complications following intracranial tumor surgery. In patients at high cardiovascular risk, ASA can safely be continued during elective brain tumor surgery to prevent potential life-threatening thromboembolic complications. Randomized clinical trials with larger sample sizes are warranted to achieve a greater statistical power.

Ultrasonography for Detecting Adhesions: Aspirin Continuation for Lung Resection Patients.

Aspirin reduces cardiovascular disease and/or stroke risks. However, perioperative aspirin use remains controversial. We assessed the efficacy of ultrasonography to facilitate video-assisted thoracic surgery (VATS). We analyzed the perioperative management of patients using aspirin and its association with bleeding events during lung cancer surgery. A total of 38 patients who underwent VATS after continuing or discontinuing aspirin were examined. Ultrasound was performed preoperatively to evaluate the pleural adhesions. Fisher's exact test was used to analyze correlations between the two groups. Dense adhesions were found at VATS ports using ultrasonography (accuracy: 100%). No differences were detected in bleeding, thrombotic events, or operative times between the aspirin and non-aspirin groups. There were differences in bleeding (p=0.009) and operative times (p=0.021) between the dense adhesion and non-dense adhesion groups. Preoperative detection of pleural adhesions using ultrasonography was useful in selecting pulmonary resection patients who continued aspirin perioperatively.

Perioperative aspirin and long-term survival in patients undergoing coronary artery bypass graft

This study aimed to examine association between perioperative uses of aspirin and long-term survival in patients undergoing CABG. A retrospective cohort study was performed in 9,584 consecutive patients receiving cardiac surgery from three tertiary hospitals. Of all the patients, 4,132 patients undergoing CABG met inclusion criteria and were divided into four groups: with or without preoperative or postoperative aspirin respectively. 30-day postoperative and long-term mortality were compared with the use of propensity scores and inverse probability weighting adjustment to reduce the treatment-selection bias. The patients taking preoperative aspirin presented significantly more with comorbidities. However, the results of this study showed that preoperative aspirin (vs. no preoperative aspirin) was associated with significantly reduced the risk of 30-day mortality in the patients undergoing CABG. Further, the results of long-term mortality showed that the patients taking preoperative aspirin and postoperative aspirin (vs. not taking) were associated with significantly reduced the risk of 4-year mortality (14.8% vs. 18.1%, RR: 0.82, 95% CI: 0.75–0.89, P = 0.005; 10.7% vs. 16.2%, RR: 0.66, 95% CI: 0.50–0.82, P = 0.003). In conclusion, this cohort study showed that perioperative (before and after surgery) use of aspirin was associated with significant reduction in 30-day mortality without significant bleeding complications, also improved long-term survival in patients undergoing CABG.

Predictors of perioperative major bleeding in patients who interrupt warfarin for an elective surgery or procedure: Analysis of the BRIDGE trial

The use of low-molecular weight heparin bridge therapy during warfarin interruption for elective surgery/procedures increases bleeding. Other predictors of bleeding in this setting are not well described. BRIDGE was a randomized, double-blind, placebo-controlled trial of bridge therapy with dalteparin 100 IU/kg twice daily in patients with atrial fibrillation requiring warfarin interruption. Bleeding outcomes were documented from the time of warfarin interruption until up to 37 days postprocedure. Multiple logistic regression and time-dependent hazard models were used to identify major bleeding predictors. We analyzed 1,813 patients of whom 895 received bridging and 918 received placebo. Median patient age was 72.6 years, and 73.3% were male. Forty-one major bleeding events occurred at a median time of 7.0 days (interquartile range, 4.0-18.0 days) postprocedure. Bridge therapy was a baseline predictor of major bleeding (odds ratio [OR]=2.4, 95% CI: 1.2-4.8), as were a history of renal disease (OR=2.9, 95% CI: 1.4-6.0), and high-bleeding risk procedures (vs low-bleeding risk procedures) (OR=2.9, 95% CI: 1.4-5.9). Perioperative aspirin use (OR=3.6, 95% CI: 1.1-11.9) and postprocedure international normalized ratio >3.0 (OR=2.1, 95% CI: 1.5-3.1) were time-dependent predictors of major bleeding. Major bleeding was most common in the first 10 days compared with 11-37 days postprocedure (OR=3.5, 95% CI: 1.8-6.9). In addition to bridge therapy, perioperative aspirin use, postprocedure international normalized ratio >3.0, a history of renal failure, and having a high-bleeding risk procedure increase the risk of major bleeding around the time of an elective surgery/procedure requiring warfarin interruption.

MP68-10 PERIOPERATIVE ASPIRIN USE DURING PERCUTANEOUS NEPHROLITHOTOMY (PCNL): OUR SINGLE CENTER EXPERIENCE.

You have accessJournal of UrologyStone Disease: Surgical Therapy VI1 Apr 2017MP68-10 PERIOPERATIVE ASPIRIN USE DURING PERCUTANEOUS NEPHROLITHOTOMY (PCNL): OUR SINGLE CENTER EXPERIENCE. Joshua Ebel and Bodo Knudsen Joshua EbelJoshua Ebel More articles by this author and Bodo KnudsenBodo Knudsen More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2326AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The rates of heart disease and nephrolithiasis continue to increase in the United States. As more patients on aspirin for secondary prevention present with large kidney stones, urologists are increasingly faced with the decision to proceed with the less effective but lower risk ureteroscopy or the higher risk but more effective percutaneous nephrolithotomy (PCNL). Leavitt, Smith, and Okeke recently published their experience performing PCNLs on seventeen patients continued on aspirin perioperatively and concluded that the procedure was safe. We wish to add our center's experience to this body of knowledge. METHODS We retrospectively reviewed our single center, single surgeon, experience of 199 PCNLs performed between January 2013 and September 2016. Hemoglobin pre- and post-operatively was recorded as were the relevant related variables of age, sex, BMI, operative duration, skin-to-stone distance, stone size, aspirin dose, aspirin indication, number of blood transfusions, and Clavien-Dindo complication classification. Correlations between hemoglobin and explanatory variables were then explored with linear regression and the Wilcoxon rank-sum test. RESULTS Of the 199 PCNLs performed at our institution in the range of our study, 27 procedures on 23 patients were conducted without discontinuing aspirin perioperatively. Coronary artery disease was the most common indication for aspirin use. In 24 cases, the patient was on 81 mg of aspirin perioperatively with the remaining three patients on 325 mg of aspirin daily. The average patient experienced a 1.3 g/dl drop in hemoglobin perioperatively. The largest drop was 4.1 g/dl, but the lowest post-operative hemoglobin was 8.2 g/dl. No significant associations were found between hemoglobin decline and age, sex, BMI, operative duration, skin-to-stone distance, or stone size. There were no Clavien-Dindo grade III or higher complications in the course of our review, and no patients required a blood transfusion or embolization. In one case, a patient required a three day inpatient stay following stent removal for continuous bladder irrigation after developing gross hematuria but this resolved spontaneously. CONCLUSIONS In our single center experience, PCNLs performed on patients taking aspirin perioperatively were not associated with the need for blood transfusion nor the occurrence of high-grade complications. It is our experience that this practice is safe when performed by expert hands. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e921-e922 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Joshua Ebel More articles by this author Bodo Knudsen More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Perioperative antiplatelet therapy and cardiovascular outcomes in patients undergoing joint and spine surgery

Study objectivePerioperative thrombotic complications after orthopedic surgery are associated with significant morbidity and mortality. The use of aspirin to reduce perioperative cardiovascular complications in certain high-risk cohorts remains controversial. Few studies have addressed aspirin use, bleeding, and cardiovascular outcomes among high-risk patients undergoing joint and spine surgery. Design/setting/patientsWe performed a retrospective comparison of adults undergoing knee, hip, or spine surgery at a tertiary care center during 2 periods between November 2008 and December 2009 (reference period) and between April 2013 and December 2013 (contemporary period). MeasurementsPatient demographics, comorbidities, management, and outcomes were ascertained using hospital datasets. Main resultsA total of 5690 participants underwent 3075 joint and spine surgeries in the reference period and 2791 surgeries in the contemporary period. Mean age was 61±13 years, and 59% were female. In the overall population, incidence of myocardial injury (3.1% vs 5.8%, P<.0001), hemorrhage (0.2% vs 0.8%, P=.0009), and red blood cell transfusion (17.2% vs 24.8%, P<.001) were lower in the contemporary period. Among 614 participants with a preoperative diagnosis of coronary artery disease (CAD), in-hospital aspirin use was significantly higher in the contemporary period (66% vs 30.7%, P<.0001); numerically, fewer participants developed myocardial injury (13.5% vs 19.3%, P=.05), had hemorrhage (0.3% vs 2.1%, P=.0009), and had red blood cell transfusion (37.2% vs 44.2%, P<.001) in the contemporary vs reference period. ConclusionsIn a large tertiary care center, the incidence of perioperative bleeding and cardiovascular events decreased over time. In participants with CAD, perioperative aspirin use increased and appears to be safe.

PD48-10 EXAMINATION OF PERIOPERATIVE OUTCOMES FOLLOWING PARTIAL NEPHRECTOMY PERFORMED ON PATIENTS REMAINING ON ANTIPLATELET THERAPY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy VI1 Apr 2016PD48-10 EXAMINATION OF PERIOPERATIVE OUTCOMES FOLLOWING PARTIAL NEPHRECTOMY PERFORMED ON PATIENTS REMAINING ON ANTIPLATELET THERAPY Timothy Ito, Philip Abbosh, Serge Ginzburg, Ithaar Derweesh, Omer Raheem, Hossein Mirheydar, Zachary Hamilton, David Chen, Marc Smaldone, Alexander Kutikov, Richard Greenberg, Rosalia Viterbo, and Robert Uzzo Timothy ItoTimothy Ito More articles by this author , Philip AbboshPhilip Abbosh More articles by this author , Serge GinzburgSerge Ginzburg More articles by this author , Ithaar DerweeshIthaar Derweesh More articles by this author , Omer RaheemOmer Raheem More articles by this author , Hossein MirheydarHossein Mirheydar More articles by this author , Zachary HamiltonZachary Hamilton More articles by this author , David ChenDavid Chen More articles by this author , Marc SmaldoneMarc Smaldone More articles by this author , Alexander KutikovAlexander Kutikov More articles by this author , Richard GreenbergRichard Greenberg More articles by this author , Rosalia ViterboRosalia Viterbo More articles by this author , and Robert UzzoRobert Uzzo More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2732AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The increased prevalence of drug-eluting coronary stents has led to a rise in the number of surgeries performed on patients who must remain on anti-platelet (AP) therapy. The risks of performing a partial nephrectomy on patients on AP therapy are underreported. In this multi-institutional study we evaluated the perioperative outcomes of these patients. METHODS Data from 1097 patients undergoing partial nephrectomy at two institutions between 2002-2014 was reviewed from prospectively collected databases. Patients were separated into three groups: AP therapy during surgery (Group I, n=67), chronic AP therapy preoperatively who stopped >5 days prior to surgery (Group II, n=254), and not on chronic AP therapy (Group III, n=776). Bleeding complications within 30 days of surgery were defined as transfusion of >2U PRBC or any readmission or secondary procedure performed primarily due to hemorrhage. Chi-square and one-way ANOVA were used for univariate analysis. Multivariable analysis (MVA) was performed using logistic regression. RESULTS The primary indication for the continuation AP therapy intraoperatively was due to cardiovascular comorbidities in 91%. Patients in group I were older (mean 66 vs. 64 and 56 years old in groups II and III respectively, p<0.0001), more frequently male (81% vs. 67% and 61%, p=0.002), less frequently Caucasian (34% vs. 20% and 20%, p=0.004) and had more comorbid conditions (mean ASA score 2.88 vs 2.42 and 2.19, p<0.0001). Group I patients experienced a significantly higher rate of bleeding complications (11.9% vs 2.4% and 2.4%, p<0.0001) and a higher transfusion rate (16.4% vs 5.9% and 4.5%, p=0.0002). On MVA controlling for clinical factors, use of any intraoperative AP therapy was predictive of an increased risk for bleeding complications (OR 4.04, p=0.005). These findings appear to be attributable to intraoperative clopidogrel use, as patients on only aspirin during partial nephrectomy did not demonstrate bleeding complication rates that were significantly higher than patients in groups II and III in univariate or multivariate analysis. CONCLUSIONS Use of clopidogrel at the time of partial nephrectomy was associated with an increased risk for bleeding complications. Perioperative aspirin use does not appear to be associated with higher rates of adverse bleeding events postoperatively. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1179 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Timothy Ito More articles by this author Philip Abbosh More articles by this author Serge Ginzburg More articles by this author Ithaar Derweesh More articles by this author Omer Raheem More articles by this author Hossein Mirheydar More articles by this author Zachary Hamilton More articles by this author David Chen More articles by this author Marc Smaldone More articles by this author Alexander Kutikov More articles by this author Richard Greenberg More articles by this author Rosalia Viterbo More articles by this author Robert Uzzo More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Update on Medical Practices That Should Be Questioned in 2015.

Overuse of medical care, consisting primarily of overdiagnosis and overtreatment, is a common clinical problem. To identify and highlight articles published in 2014 that are most likely to influence medical overuse, organized into the categories of overdiagnosis, overtreatment, and methods to avoid overuse, and to review these articles and interpret them for their importance to clinical medicine. A structured review of English-language articles in PubMed published in 2014 and a review of tables of contents of relevant journals to identify potential articles that related to medical overuse in adults. We reviewed 910 articles, of which 440 addressed medical overuse. Of these, 104 were deemed most relevant based on the presentation of original data, quality of methods, magnitude of clinical effect, and number of patients potentially affected. The 10 most influential articles were selected by author consensus using the same criteria. Findings included lack of benefit for screening pelvic examinations (positive predictive value <5%), carotid artery screening (no reduction in stroke), and thyroid ultrasonography (15-fold increase in thyroid cancer). The harms of cancer screening included unnecessary surgery and complications. Head computed tomography was an overused diagnostic test (clinically significant findings in 4% [7 of 172] of head computed tomographic scans). Overtreatment included acetaminophen for low back pain, perioperative aspirin use, medications to increase high-density lipoprotein cholesterol level, stenting for renal artery stenosis, and prolonged opioid use after surgery (use >90 days in 3% [1229 of 39,140] of patients). Many common medical practices should be reconsidered. It is anticipated that our review will promote reflection on these 10 articles and lead to questioning of other non-evidence-based practices.

Outcomes of Laparoscopic Partial Nephrectomy in Patients Continuing Aspirin Therapy

A clinical dilemma surrounds the use of aspirin therapy during laparoscopic partial nephrectomy. Despite reduced cardiac morbidity with perioperative aspirin use, fear of bleeding related complications often prompts discontinuation of therapy before surgery. We evaluate perioperative outcomes among patients continuing aspirin and those in whom treatment is stopped preoperatively. A total of 430 consecutive cases of laparoscopic partial nephrectomy performed between January 2012 and October 2014 were reviewed. Patients on chronic aspirin therapy were stratified into on aspirin and off aspirin groups based on perioperative status of aspirin use. Primary end points evaluated included estimated intraoperative blood loss and incidence of bleeding related complications, major postoperative complications, and thromboembolic events. Secondary outcomes included operative time, transfusion rate, length of hospital stay, rehospitalization rate and surgical margin status. Among 101 (23.4%) patients on chronic aspirin therapy, antiplatelet treatment was continued in 17 (16.8%). Bleeding developed in 1 patient in the on aspirin group postoperatively and required angioembolization. Conversely 1 myocardial infarction was observed in the off aspirin cohort. There was no significant difference in the incidence of major postoperative complications, intraoperative blood loss, transfusion rate, length of hospital stay and rehospitalization rate. Operative time was increased with continued aspirin use (181 vs 136 minutes, p=0.01). Laparoscopic partial nephrectomy is safe and effective in patients on chronic antiplatelet therapy who require perioperative aspirin for cardioprotection. Larger, prospective studies are necessary to discern the true cardiovascular benefit derived from continued aspirin therapy as well as better characterize associated bleeding risk.

926 Perioperative aspirin use associated with increased risk for bleeding complication following partial nephrectomy

926 Perioperative aspirin use associated with increased risk for bleeding complication following partial nephrectomy

Perioperative aspirin management after POISE-2: some answers, but questions remain.

Aspirin constitutes important uninterrupted lifelong therapy for many patients with cardiovascular (CV) disease or significant (CV) risk factors. However, whether aspirin should be continued or withheld in patients undergoing noncardiac surgery is a common clinical conundrum that balances the potential of aspirin for decreasing thrombotic risk with its possibility for increasing perioperative blood loss. In this focused review, we describe the role of aspirin in treating and preventing cardiovascular disease, summarize the most important literature on the perioperative use of aspirin (including the recently published PeriOperative ISchemic Evaluation [POISE]-2 trial), and offer current recommendations for managing aspirin during the perioperative period. POISE-2 suggests that aspirin administration during the perioperative period does not change the risk of a cardiovascular event and may result in increased bleeding. However, these findings are tempered by a number of methodological issues related to the study. On the basis of currently available literature, including POISE-2, aspirin should not be administered to patients undergoing surgery unless there is a definitive guideline-based primary or secondary prevention indication. Aside from closed-space procedures, intramedullary spine surgery, or possibly prostate surgery, moderate-risk patients taking lifelong aspirin for a guideline-based primary or secondary indication may warrant continuation of their aspirin throughout the perioperative period.

Weighing the Risks of Perioperative Aspirin

Neurosurgeons are wary of perioperative aspirin use given the potentially catastrophic effects of intraoperative or postoperative bleeding. In a poll of German spine surgeons, only 7 of 142 surgeons would perform elective surgery on a patient taking aspirin (3). With the exception of endovascular procedures, aspirin is generally discontinued 7e10 days before surgery. This time scale is derived from recommendations made by the American College of Chest Physicians and may be adjusted depending on the patient’s specific cardiac risk (2). No recommendations exist at the present time regarding the appropriate time period to restart aspirin postoperatively, leaving this decision to the surgeon. When considering perioperative aspirin use, the objective is to balance the risks of perioperative and postoperative hemorrhage against myocardial infarction and stroke. Neurosurgical literature to guide this decision-making process is sparse, especially in regard to intracranial surgery. In terms of aspirin use in spine surgery, only 2 recent publications address the topic, but these studies evaluated only estimated blood loss intraoperatively and postoperatively via wound drains (4, 5). The studies failed to address whether aspirin use was associated with hemorrhagic complications or if its discontinuation predisposed patients to cardiac events. A recent article in the New England Journal of Medicine (1) attempts to answer this question. Devereaux et al. (1) published their study as part of the POISE-2 (PeriOperative ISchemic Evaluation-2) trial. This prospective, randomized, multicenter, controlled trial sought to determine the effect of perioperatively administered aspirin versus placebo on the 30-day risk of death or nonfatal myocardial infarction in patients undergoing noncardiac surgery. Secondary outcome measures included risk ofmajor bleeding at the surgical site or elsewhere, risk of stroke, and the effect of coadministered clonidine. Only patients with cardiovascular risk factors, who could benefit from aspirin use, were included in the study. Patients were recruited for enrollment from 135 hospitals in 23 countries. Patients undergoing intracranial surgery were excluded. The study enrolled 10,010 patients divided into patients already taking aspirin (continuation stratum; n1⁄4 4382 patients) and patients not taking aspirin (initiation stratum; n 1⁄4 5628 patients) at the start of the trial. Patients from both strata were randomly assigned to either the aspirin group (n1⁄4 4998 patients) or the placebo group (n 1⁄4 5012 patients). Patients received 200 mg of aspirin or placebo just before surgery and continued themedication

Safety of perioperative aspirin therapy in pancreatic operations

Antiplatelet therapy with aspirin is prevalent among patients presenting for operative treatment of pancreatic disorders. Operative practice has called for the cessation of aspirin 7-10 days before elective procedures because of the perceived increased risk of procedure-related bleeding. Our practice at Thomas Jefferson University has been to continue aspirin therapy throughout the perioperative period in patients undergoing elective pancreatic surgery. Records for patients undergoing pancreatoduodenectomy, distal pancreatectomy, or total pancreatectomy between October 2005 and February 2012 were queried for perioperative aspirin use in this institutional research board-approved retrospective study. Statistical analyses were performed with Stata software. During the study period, 1,017 patients underwent pancreatic resection, of whom 289 patients (28.4%) were maintained on aspirin through the morning of the operation. Patients in the aspirin group were older than those not taking aspirin (median 69 years vs 62 years, P < .0001). The estimated intraoperative blood loss was similar between the two groups, aspirin versus no aspirin (median 400 mL vs 400 mL, P = .661), as was the rate of blood transfusion anytime during the index admission (29% vs 26%, P = 0.37) and the postoperative duration of hospital stay (median 7 days vs 6 days, P = .103). The aspirin group had a slightly increased rate of cardiovascular complications (10.1% vs 7.0%, P=.107), likely reflecting their increased cardiovascular comorbidities that led to their physicians recommending aspirin therapy. Rates of pancreatic fistula (15.1% vs 13.5%, P=.490) and hospital readmissions were similar (16.9% vs 14.9%, P=.451). This is the first study to report that aspirin therapy is not associated with increased rates of perioperative bleeding, transfusion requirement, or major procedure related complications after elective pancreatic surgery. These data suggest that continuation of aspirin is safe and that the continuation of aspirin should be considered acceptable and preferable, particularly in patients with perceived substantial medical need for treatment with antiplatelet therapy.