Preoperative Antiplatelet Therapy Research Articles

Thromboelastography with Platelet Mapping to Optimize Surgical Timing in Coronary Artery Bypass Grafting Patients on P2Y12 Receptor Blockers Therapy.

An increasing number of patients attending coronary artery bypass grafting (CABG) receive preoperative antiplatelet drugs (acetylsalicylic acid, clopidogrel, prasugrel, ticagrelor). The optimal assessment of preoperative platelet function is the aim of this study for a shorter surgical timing in patients undergoing elective coronary artery bypass grafting. This study was performed on patients presenting for first-time isolated CABG on therapy with an P2Y12 receptor blockers loading dose (clopidogrel [300 mg] or prasugrel [60 mg] or ticagrelor [180 mg]) or P2Y12 receptor blockers maintenance therapy at least for five days (clopidogrel [75 mg once daily], prasugrel [10 mg once daily], ticagrelor [90 mg twice daily]). All patients received simultaneously acetylsalicylate acid (100 mg daily). Exclusion criterion was emergency CABG regardless of preoperative antiplatelet and anticoagulant therapy. All patients' data were recorded in an Excel® file and analyzed using RStudio® software. Forty-eight consecutive adult patients presenting for CABG were enrolled. Preoperative thromboelastography-platelet mapping showed platelet resistance to P2Y12 blockers receptor - 25% for clopidogrel (6/24), 33% for ticagrelor (6/18), 33% for prasugrel (2/6), and this data was useful to obtain a shorter CABG waiting time in comparison with current guidelines (2.7 vs. five days for clopidogrel, 2.5 vs. five days for ticagrelor, 3.3 vs. seven days for prasugrel). Preoperative thromboelastography-platelet mapping is helpful to detect harmful P2Y12 receptor blockers resistance and to minimize CABG waiting time avoiding unnecessary and life-threatening delays.

Analysis of influencing factors and construction of risk prediction model for postoperative thrombocytopenia in critically ill patients with heart disease

ObjectiveTo analyze the influencing factors of postoperative thrombocytopenia in critically ill patients with heart disease and construct a nomogram prediction model.MethodsFrom October 2022 to October 2023, 319 critically ill patients with heart disease who visited our hospital were collected and separated into postoperative thrombocytopenia group (n = 142) and no postoperative thrombocytopenia group (n = 177) based on their postoperative thrombocytopenia, Logistic regression analysis was applied to screen risk factors for postoperative thrombocytopenia in critically ill patients with heart disease; R software was applied to construct a nomogram for predicting postoperative thrombocytopenia in critically ill patients with heart disease, and ROC curves, calibration curves, and Hosmer-Lemeshow goodness of fit tests were applied to evaluate nomogram.ResultsA total of 142 out of 319 critically ill patients had postoperative thrombocytopenia, accounting for 44.51%. Logistic regression analysis showed that gender (95% CI 1.607–4.402, P = 0.000), age ≥ 60 years (95% CI 1.380–3.697, P = 0.001), preoperative antiplatelet therapy (95% CI 1.254–3.420, P = 0.004), and extracorporeal circulation time > 120 min (95% CI 1.681–4.652, P = 0.000) were independent risk factors for postoperative thrombocytopenia in critically ill patients with heart disease. The area under the ROC curve was 0.719 (95% CI: 0.663–0.774). The slope of the calibration curve was close to 1, and the Hosmer-Lemeshow goodness of fit test was χ2 = 6.422, P = 0.491.ConclusionPostoperative thrombocytopenia in critically ill patients with heart disease is influenced by gender, age ≥ 60 years, preoperative antiplatelet therapy, and extracorporeal circulation time > 120 min. A nomogram established based on above multiple independent risk factors provides a method for clinical prediction of the risk of postoperative thrombocytopenia in critically ill patients with heart disease.

Type II endoleaks after fenestrated/branched endografting for juxtarenal and pararenal aortic aneurysms

ObjectivePersistent type II endoleaks (pEL2s) are not uncommon after endovascular aneurysm repair and their impact on long-term outcomes is well-documented. However, their occurrence and natural history after fenestrated/branched endografting (F/B-EVAR) for juxtarenal and pararenal aneurysms (J/P-AAAs) have been scarcely investigated. Aim of this study was to report incidence, risk factors, and natural history of pEL2 after F/B-EVAR in J/P-AAAs. MethodsBetween 2016 and 2022, all J/P-AAAs undergoing F/B-EVAR were prospectively collected and retrospectively analyzed. EL2 were assessed at the completion angiography, at 30 days and after 6 months as primary outcomes. Preoperative risk factors for pEL2, follow-up survival, freedom from reinterventions (FFR) and aneurysm shrinkage (≥5 mm) were considered as secondary outcomes. ResultsOf 132 patients, there were 88 (67%) JAAAs and 44 (33%) PAAAs. Seventeen EL2 (13%) were detected at the completion angiography and 36 (27%) at 30-day computed tomography angiography. The mean follow-up was 28 ± 23 months. Eleven (31%) EL2 sealed spontaneously within 6 months and three new cases were detected, for an overall of 28 pEL2/107 patients (26%) with available radiological follow-up of ≥6 months. Preoperative antiplatelet therapy (odds ratio, 4.7; 95% confidence interval [CI[, 1-22.1; P = .05), aneurysm thrombus volume of ≤40% and six or more patent aneurysm afferent vessels (odds ratio, 7.2; 95% CI, 1.8-29.1; P = .005) were independent risk factors for pEL2. The estimated 3-year survival was 80%, with no difference between cases with and without pEL2 (78% vs 85%; P = .08). The estimated 3-year FFR was 86%, with no difference between cases with and without pEL2 (81% vs 87%; P = .41). Four cases (3%) of EL2-related reinterventions were performed. In 65 cases (49%), aneurysm shrinkage was detected. pEL2 was an independent risk factor for absence of aneurysm shrinkage during follow-up (hazard ratio, 3.2; 95% CI, 1.2-8.3; P = .014). Patients without shrinkage had lower follow-up survival (64% vs 86% at 3-year; P = .009) and FFR (74% vs 90% at 3 years; P = .014) than patients with shrinkage. ConclusionsPEL2 is not infrequent (26%) after F/B-EVAR for J/P-AAAs and is correlated with preoperative antiplatelet therapy, aneurysm thrombus volume of ≤40%, and six or more patent sac afferent vessels. Patients with pEL2 have a diminished aneurysm shrinkage, which is correlated with lower follow-up survival and FFR compared with patients with aneurysm shrinkage.

Impact of preoperative antiplatelet / anticoagulant therapy on postoperative bleeding rate in anorectal surgery. Analysis of a high-volume proctologic and pelvic floor clinical center

IntroductionThe aim of the present study is to analyze the impact of preoperative antiplatelet and/or anticoagulant therapy on postoperative bleeding in proctologic surgery. Material and MethodsA retrospective study was conducted on a consecutive series of patients who underwent to proctologic surgery between January 2016-December 2018. The patients were divided in two groups: non-therapy group without any cardiovascular problem and therapy group that received antiplatelet and/or anticoagulant therapy. A sub analysis was carried out stratifying the patients according to the type of preoperative therapy and the type of surgery. ResultsA total of 1832 operated patients were collected; 8.7 % of them received antiplatelet or anticoagulant therapy preoperatively. The postoperative bleeding rate was 2.8 % (2.1 % in the non-therapy group, and 10.1 % in the therapy group). The re-operation rate after bleeding was 1.2 % (1.1 % of non-therapy group, and 3.1 % therapy group). The re-operation rate in patients with postoperative bleeding was 51.4 % and 31.3 % for therapy and non-therapy group, respectively. The interval time between surgery and bleeding, was 7.8 days (non-therapy) and 8.5 days (therapy). Hemorrhoid's surgery showed to have the higher postoperative bleeding rate. The use of DOACs and OAC showed the highest rates of bleeding (20 % vs 36.4 %). ConclusionThe constant increase of patients with antiplatelet/anticoagulant treatment requiring surgery for benign diseases reveals a significant increase the post-operative risk of bleeding. The management of these complex patients needs to be discussed in a multidisciplinary team with the aim to follow shared guidelines but also to customize the approach.

Nondual Antiplatelet Therapy Versus Dual Antiplatelet Therapy Before Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-analysis.

Transcatheter aortic valve replacement (TAVR) is an interventional procedure performed in patients with severe aortic stenosis and often required perioperative antiplatelet therapy. Most previous studies have focused on antiplatelet therapy following TAVR. However, few studies have investigated the prognostic effect of preoperative antiplatelet therapy in patients undergoing TAVR. This study aimed to compare the efficacy and safety of nondual antiplatelet therapy (non-DAPT) and DAPT before TAVR. We performed a systematic search of Embase, PubMed, and Web of Science until February 2023. Studies were eligible if they compared non-DAPT (single antiplatelet therapy or no antiplatelet therapy) with DAPT in patients before TAVR. A total of 5 studies, including 2329 patients, met the inclusion criteria and were included in the meta-analysis. Preoperative non-DAPT significantly decreased minor bleeding events compared with preoperative DAPT [odds ratio 0.58; 95% confidence interval: 0.44-0.76]. There were no significant differences in the incidence of other bleeding events, transfusions, stroke, myocardial infarction, or all-cause death. Preoperative single antiplatelet therapy significantly decreased the incidence of major bleeding compared with DAPT (odds ratio 0.14; 95% confidence interval: 0.04-0.48). Preoperative non-DAPT significantly reduced minor bleeding events in patients undergoing TAVR, without increasing the risk of stroke and myocardial infarction.

Efficacy and safety of flow diverter combined with coil embolization and evidence-based antithrombotic regimen in the treatment of ruptured aneurysms.

The use of a flow diverter (FD) in the treatment of ruptured aneurysms is limited due to the increased risk of perioperative ischemia and hemorrhagic complications. Adjunctive coil embolization and an evidence-based antithrombotic regimen may improve therapeutic safety, although evidence from relevant clinical research is limited. The authors' aim was to further assess the perioperative safety and long-term efficacy of this strategy. Data on patients with FD insertion and coil embolization were collected retrospectively at two centers. The perioperative antithrombotic regimen consists of intraoperative tirofiban and continues for 24 hours postoperatively, with the initiation of an orally administered dual-antiplatelet regimen 4 hours prior to tirofiban cessation, rather than purposeful preoperative antiplatelet therapy. Perioperative cerebral ischemia and hemorrhagic complications and long-term aneurysm occlusion rates were recorded to evaluate the safety and efficacy of the procedure, respectively. In total, 67 cases were screened and 41 cases were ultimately included in this study. A total of 2 cases (4.9%) of perioperative cerebral hemorrhagic events occurred, 1 of which (2.4%) was attributable to rerupture of the aneurysm. Cerebral ischemic events were reported in 3 patients, including 1 with cortical thromboembolism and 2 with perforator occlusion of the basilar artery. A median 8-month follow-up was attained in 25 patients (61.0%), with a 92% complete or near-complete occlusion rate. FD insertion combined with coil embolization is a potentially safe and effective therapeutic strategy for ruptured aneurysms when accompanied with perioperative evidence-based antithrombotic therapy.

Preoperative antiplatelet therapy may be a risk factor for postoperative ischemic complications in intracranial hemorrhage patients

Background and purpose Spontaneous intracranial hemorrhage (ICH) patients are still at risk of postoperative ischemic complications (PICs) after surgery. In addition, the proportion of patients receiving antiplatelet therapy (APT) in ICH patients increased significantly with age. This study aims to evaluate the impact of preoperative antiplatelet therapy on PICs in ICH patients. Methods This is a cohort study that retrospectively analyzed the data of ICH patients who underwent surgical treatment. PICs rate was compared between patients with preoperative ATP and those without preoperative ATP. Univariate and multivariate analyses were conducted to evaluate the impact of preoperative APT on PICs. In addition, Kaplan-Meier method was used for survival analysis and the impact of PICs on patients’ postoperative outcomes was evaluated. Results A total of 216 patients were included in this study. There were 47 patients (21.76%) with preoperative APT; 169 patients (78.24%) without preoperative APT. The incidence of PICs in the APT group was significantly higher when compared with that in the nAPT group (36.17% vs. 20.71%, p = 0.028＜0.05). Furthermore, significant differences were both observed in multivariate analysis (p = 0.035＜0.05) and survival analysis (log rank χ2 = 5.415, p = 0.020＜0.05). However, there was no significant difference between the outcomes of patients suffering from PICs and that of patients not suffering from PICs (p = 0.377 > 0.05). Conclusions In conclusion, preoperative APT may be a risk factor for PICs in ICH patients undergoing surgical treatment significantly.

Predictors of Failed Same-Day Catheter Removal After Holmium Laser Enucleation of the Prostate

ObjectiveTo determine factors associated with failure of same-day trial of void (SDTOV) following holmium laser enucleation of the prostate (HoLEP). BackgroundHoLEP is increasingly utilized for patients with benign prostatic hyperplasia. Advancements in technology have improved operative efficiency and hemostasis making same-day, catheter-free discharge possible. MethodsWe conducted a retrospective review on 190 patients undergoing HoLEP from July, 2021 to January, 2022 by a single center. We assessed pre- and intra-operative variables associated with our primary outcome: failure of same-day catheter removal. Post-operative complications and outcomes at a ≤7 days and 3-month follow up were examined. Continuous and categorical variables were analyzed using unpaired t-tests (Mann Whitney) and chi-square, respectively. Univariate and multivariable logistic regression models were fitted to examine the associations of failed SDTOV. ResultsOf 190 candidates for a SDTOV, 90% (171/190) were successful. We found no difference between SDTOV success and failures with regards to age, comorbidities, presence of pre-operative urinary retention, anesthesia factors, operative time, volume resected, enucleation time, and morcellation time (all P>0.05). Pre-operatively, 26.3% (50/190) were on antiplatelet and 6.3% (12/190) were on anticoagulation. While pre-operative antiplatelet therapy was not associated with SDTOV failure (P=0.78), pre-operative anticoagulation use was (4.7% vs. 21.1%, P=0.021). Patients who continued anticoagulation through surgery had the highest rate of SDTOV failure (2.3% (4/171) vs. 15.8% (3/19), P=0.023). For those with successful SDTOV, 4.1% (7/171) required catheterization following discharge. At 3 months, no patient required catheterization. ConclusionOn the day of surgery, patients eligible for SDTOV successfully voided 90% of the time. History of preop anticoagulation, whether continued or held, increased SDTOV failure.

Safety of early posterior fusion surgery without endovascular embolization for asymptomatic vertebral artery occlusion associated with cervical spine trauma.

Vertebral artery occlusion (VAO) is an increasingly recognized complication of cervical spine trauma. However, the management strategy of VAO remains heavily debated. Therefore, the aim of this retrospective study was to investigate the safety of early fusion surgery for traumatic VAO. This study included a total of 241 patients (average age 64.7years; 201 men) who underwent early surgical treatment for acute cervical spine injury between 2012 and 2019. The incidence of VAO, cerebral infarction rates, the recanalization rates, and cerebral thromboembolism after recanalization were retrospectively analyzed. VAO occurred in 22 patients (9.1%). Of the 22 patients with VAO, radiographic cerebral infarction was detected in 4 patients (21.1%) at initial evaluation, including 1 symptomatic medullar infarction (4.5%) and 3 asymptomatic cerebrum infarctions. A patient who experienced right medullar infarction showed no progression of the neurologic damage. Follow-up imaging revealed that the VAOs of 9 patients (40.9%) were recanalized, and the recanalization did not correlate with clinical adverse outcomes. The arteries of the remaining 13 (59.1%) patients remained occluded and clinically silent until the final follow-up (mean final follow-up 33.0months). Despite the lack of a concurrent control group with preoperative antiplatelet therapy or endovascular embolization for VAO, our results showed low symptomatic stroke rate (4.5%), high recanalization rate (40.9%), and low mortality rate (0%). Therefore, we believe that the indication for early stabilization surgery as management strategy of asymptomatic VAO might be one of the safe and effective treatment options for prevention of symptomatic cerebral infarction.

Recuperadores de sangre postoperatorios tras la artroplastia de rodilla: ¿siguen siendo útiles? Un estudio de cohortes retrospectivo

Background and Goal of Study: Blood salvage (BS) is important to implement the second pillar of Patient Blood Management to avoid anaemia after total knee arthroplasty (TKA). Our primary outcome was to assess BS usefulness to decrease allogenic blood transfusion (ABT) rate in TKA. Materials and Methods: a retrospective, observational cohort study was conducted on consecutive patients scheduled for TKA with BS or not. Demographic, comorbidity, surgical and anesthetic data, laboratory pre and postoperative results, volume of blood drained, and reinfused from BS and the requirement of ABT were recorded. Parametric and non-parametric tests were employed. p< 0.05 was accepted as significant. Results: 260 patients were included (130 per cohort). The amount of postoperative bleeding was 713.1 +445.4 ml. 26.5% received ABT. BS reduced transfusion in 13,1% (p=0,024) with RR 1,65 (CI 1,085-2,52)]. Risk factors for postoperative bleeding were: male gender, atrial fibrillation, preoperative anti-platelet therapy and cementless primary TKA. Risk factors for ABT: ASA > II, preoperative hemoglobin < 13 g/dl, knee revision, anti-platelet therapy, longer surgery time. Patients transfused had lower hemoglobin values (p<0.001), and longer medium LOS (+2.5 days, p=0.026). Conclusion: The use of BS in TKA showed benefits reducing allogenic blood transfusion and length of hospital stay. BS would remain an effective, safe and cheap alternative to tranexamic acid in patients with high risk of thromboembolism events operated of TKA.

Relationship of pharmacotherapy and the incidence of embolic complications of carotid reconstructive surgery

Aim. To evaluate the relationship between lipid-lowering and antiplatelet therapy and the incidence of cerebral microembolism and related complications in open and endovascular revascularization of the carotid arteries (CA).Material and methods. This single-center study involved patients with internal CA stenosis. The patients were divided into 2 groups depending on the surgery type performed: carotid endarterectomy (CEA) — 163 patients; CA stenting (CAS) — 71 patients. All patients underwent intraoperative transcranial Doppler monitoring to register cerebral embolism during CAS and CE.Results. In CAS, microembolism episodes were observed in 66,2% vs 22,1% of patients in the CEA group (p=0,04), the largest number of which was recorded during catheterization of the internal CA and embolic filter installation (p=0,000). There were no significant differences between the groups in terms of the stroke incidence. In 8 patients in the CAS group and 1 patient in the CEA group, a transient ischemic attack was observed within 30 days after surgery (p=4x10-4 ). Intraoperative embolism was a predictor of a neurological event in the early postoperative period (odds ratio (OR), 33,08; 95% confidence interval (CI): 3,49-56,37 (p6 months before surgery reduces the likelihood of embolism by 4 times (OR 0,25; 95% CI: 0,11-0,58 (p=0,001), while lipid-lowering and antiplatelet therapy combination — by 12,5 times (OR, 0,08; 95% CI: 0,01-0,40 (p=0,001)).Conclusion. Preoperative antiplatelet and statin therapy reduces the likelihood of embolism during the CA revascularization procedure.

Outcomes of preoperative antiplatelet therapy in patients with acute type A aortic dissection.

Acute type A aortic dissection (ATAAD) is life-threatening and requires immediate surgery. Sudden chest pain may lead to a risk of misdiagnosis as an acute coronary syndrome and may lead to subsequent antiplatelet therapy (APT). We used the Chinese Acute Aortic Syndrome (AAS) Collaboration Database to study the effects of APTon clinical outcomes. The AAS database is a retrospective multicentre database where 31 of 3092 patients had APT with aspirin or clopidogrel or both before surgery. Before and after propensity score matching (PSM), the incidence of complications and mortality was compared between APT and non-APT patients by using a logistic regression model. The sample remaining after PSMwas 30 in the APT group and 80 in the non-APT group. The sample remaining after matching was 30 in the APT group and 80 in the non-APT group. We found 10 cases with percutaneous coronary intervention in the APT group (33.3%). The APT group received more volume of packed red blood cells, 8.4 ± 6.05 units; plasma, 401.67 ± 727 ml, and platelet transfusion (14.07 ± 8.92 units). The drainage volume was much more in the APT group (5009.37 ± 2131.44 ml, p = .004). Mortality was higher in APT group (26% vs. 10%, p = .027). The preoperative APT was an independent predictor of mortality (odds ratio: 6.808, 95% confidence interval: 1.554-29.828, p = .011). APT before ATAAD repair was associated with more transfusions and higher early mortality. The timing of surgery should be carefully considered based on the patient's status and the surgeon's experience.

The Effect of Preoperative Antiplatelet Therapy on Early Postoperative Rehemorrhage and Outcomes in Patients With Spontaneous Intracranial Hematoma.

Background and PurposeThe effect of antiplatelet therapy (APT) on early postoperative rehemorrhage and outcomes of patients with spontaneous intracerebral hemorrhage (ICH) is still unclear. This study is to evaluate the effect of preoperative APT on early postoperative rehemorrhage and outcomes in ICH patients.MethodsThis was a multicenter cohort study. ICH patients undergoing surgery were divided into APT group and no antiplatelet therapy (nAPT) group according to whether patients received APT or not. Chi-square test, t-test, and Mann–Whitney U test were used to compare the differences in variables, postoperative rehematoma, and outcomes between groups. Multivariate logistics regression analysis was used to correct for confounding variables, which were different in group comparison.ResultsOne hundred fifty ICH patients undergoing surgical treatment were consecutively included in this study. Thirty five (23.33%) people were included in the APT group, while 115 (76.67%) people were included in the nAPT group. The incidence of early postoperative rehemorrhage in the APT group was significantly higher than that in the nAPT group (25.7% VS 10.4%, p = 0.047 < 0.05). After adjustment for age, ischemic stroke history, and ventricular hematoma, preoperative APT had no significant effect on early postoperative rehemorrhage (p = 0.067). There was no statistical difference between the two groups in early poorer outcomes (p = 0.222) at 14 days after surgery. After adjustment for age, ischemic stroke history, and ventricular hematoma, preoperative APT also had no significant effect on early poorer modified Rankin Scale (mRS) (p = 0.072).ConclusionIn conclusion, preoperative APT appears to be safe and have no significant effect on early postoperative rehematoma and outcomes in ICH patients.

Consensus Decision-Making for the Management of Antiplatelet Therapy before Non-Cardiac Surgery in Patients Who Underwent Percutaneous Coronary Intervention With Second-Generation Drug-Eluting Stents: A Cohort Study.

BackgroundAlthough antiplatelet therapy (APT) has been recommended to balance ischemic‐bleeding risks, it has been left to an individualized decision‐making based on physicians' perspectives before non‐cardiac surgery. The study aimed to assess the advantages of a consensus among physicians, surgeons, and anesthesiologists on continuation and regimen of preoperative APT in patients with coronary drug‐eluting stents.Methods and ResultsA total of 3582 adult patients undergoing non‐cardiac surgery after percutaneous coronary intervention with second‐generation stents was retrospectively included from a multicenter cohort. Physicians determined whether APT should be continued or discontinued for a recommended period before non‐cardiac surgery. There were 3103 patients who complied with a consensus decision. Arbitrary APT, not based on a consensus decision, was associated with urgent surgery, high bleeding risk of surgery, female sex, and dual APT at the time of preoperative evaluation. Arbitrary APT independently increased the net clinical adverse event (adjusted odds ratio [ORadj], 1.98; 95% CI, 1.98–3.11), major adverse cardiac event (ORadj, 3.11; 95% CI, 1.31–7.34), and major bleeding (ORadj, 2.34; 95% CI, 1.45–3.76) risks. The association was consistently noted, irrespective of the surgical risks, recommendations, and practice on discontinuation of APT.ConclusionsMost patients were treated in agreement with a consensus decision about preoperative APT based on a referral system among physicians, surgeons, and anesthesiologists. The risk of perioperative adverse events increased if complying with a consensus decision was failed.RegistrationURL: https://www.clinicaltrials.gov; Unique identifier: NCT03908463.

Periprocedural Hemoglobin Levels Affect Amputation Rates in Patients Undergoing Interventions for Critical Limb Ischemia

Critical limb-threatening ischemia (CLTI) of the lower extremity is associated with high rates of morbidity, including amputation and death. Unfortunately, there is a paucity of data related to how periprocedural metrics affect the success of these interventions for CLTI. Perioperative anemia has been shown to affect outcomes in patients suffering from myocardial ischemia. It can be postulated that the same physiologic principles can be applied to CLTI. We hypothesize that perioperative anemia may contribute to a higher risk for amputation in patients receiving interventions for CLTI. We performed a single-center, retrospective cohort study of patients undergoing procedures for CLTI at The Ohio State University Wexner Medical Center. Patients aged 18 to 100 years with International Classification of Diseases, Ninth Revision or Tenth Revision coding for CLTI of the lower extremities were included. Patients with interventions for claudication or acute limb ischemia were excluded. Demographic data and hemoglobin levels before intervention were obtained. The primary outcome was amputation of the affected limb after intervention. Secondary outcomes included the need for reintervention, 30-day mortality, and 30-day major complication rate. Statistical analyses using univariate and multivariate analysis with logistic regression models were performed to compare amputation rates with these variables. We identified 258 patients undergoing interventions for CLTI between 2006 and 2018. Fifty-nine (22.9%) went on to amputation. Multivariate analysis revealed that patients with hemoglobin levels of <12 g/dL had increased risk of amputation (odds ratio [OR], 2.57; confidence interval [CI], 1.12-5.85; P = .0003). In addition, age >80 years (OR, 0.228; CI, 0.060-0.871; P = .031), nonwhite race (OR, 2.83; CI, 1.32-6.05; P = .007), and male sex (OR, 3.4; CI, 1.61-7.24; P = .001) were identified as risk factors for amputation. Patients without preoperative antiplatelet therapy also had increased risk (OR, 0.31; CI, 0.133-0.697; P = .005). In this study, we showed that periprocedural hemoglobin levels below normal were an independent risk factor for amputation in our cohort of patients. Further prospective studies are indicated to identify whether hemoglobin should be a targeted, adjustable risk factor in patients undergoing interventions for CLTI.

Risk of postoperative thromboembolic complication after major digestive surgery in patients receiving antiplatelet therapy: Lessons from more than 3,000 operations in a single tertiary referral hospital

BackgroundAlthough recent studies have suggested that the continuation of preoperative antiplatelet therapy with aspirin does not affect intraoperative or postoperative bleeding in patients undergoing digestive surgery, its preventive effect against thromboembolic complication remains largely unknown. MethodsA total of 3,072 patients who underwent major digestive surgery (esophago-gastrointestinal and hepatobiliary-pancreatic resection for malignancy) between 2005 and 2018 at our institution were enrolled in this study. The patients were divided into 3 groups: patients continuing to receive preoperative antiplatelet therapy with aspirin (continued-antiplatelet therapy group, n = 425), those discontinuing preoperative antiplatelet therapy (discontinued-antiplatelet therapy group, n = 549), and those who were not receiving antiplatelet therapy (non-antiplatelet therapy group, n = 2,117). The CHADS2 and the CHA2DS2-VASc scoring system were used to assess potential thromboembolic risk. Surgical outcomes were compared between the groups and the risk factors for thromboembolic complication, bleeding complication, and operative mortality were determined by multivariate analysis. ResultsThere was no difference between the discontinued-antiplatelet therapy and continued-antiplatelet therapy groups in the rate of high risk patients categorized by CHADS2 and CHA2DS2-VASc scores; however, the occurrence of thromboembolic complication in the discontinued-antiplatelet therapy group was significantly higher compared with the continued-antiplatelet therapy group (2.8% vs 0.5%; P = .006). In a multivariate analysis using the whole cohort, discontinuation of antiplatelet therapy (odds ratio = 4.39; P < .001), poor performance status (odds ratio = 4.14; P = .001), and hypertension (odds ratio = 3.46; P = .005) were the independent risk factors for thromboembolic complication. In the groups of patients receiving antiplatelet therapy, multivariate analysis showed that preoperative aspirin continuation had a significant negative impact (odds ratio = 0.10, P = .029) on the occurrence of thromboembolic complication, but did not affect either postoperative bleeding complication or operative mortality. ConclusionDiscontinuation of antiplatelet therapy during major digestive surgery is the most significant risk factor for thromboembolic complication, and the continuation of preoperative aspirin therapy significantly reduces the occurrence of thromboembolic complication in patients receiving antiplatelet therapy. It is suggested that the preoperative continuation of aspirin monotherapy is one of the preferred options to prevent severe thromboembolic events during major digestive surgery in patients receiving antiplatelet therapy.

Start of Antiplatelet Therapy Increases the Prevalence of Intraplaque Hemorrhage in Patients With Advanced Carotid Artery Lesions: A Longitudinal MR Imaging Study

Introduction: Intraplaque hemorrhage (IPH) is an important feature of plaque vulnerability. Patients with a history of transient ischemic attack or stroke are treated with platelet aggregation inhibitors to prevent secondary myocardial infarction or ischemic stroke. Although antiplatelet medication is effective in reduction of clot formation, it also has adverse effects. It has therefore been hypothesized that platelet aggregation inhibitors could also initiate the onset or progression of IPH. A histopathological study on 154 carotid endarterectomy plaques found that preoperative antiplatelet therapy was associated with an increase in the prevalence of repeated IPH in symptomatic carotid plaques. This longitudinal study investigates the effect of antiplatelet agents on the prevalence of IPH. Methods: 63 symptomatic patients underwent carotid MRI at baseline and after two years of follow-up. Presence of IPH in both carotid arteries was scored. Medication prescription before and after the index event and after follow-up was collected.The presence of IPH was determined using MP-RAGE images and analysed blinded for the clinical data using dedicated vessel wall analysis software (VesselMass). IPH was considered present when a hyperintense signal, compared to the sternocleidomastoid muscle, was visible in the bulk of the plaque. Results: A significant higher prevalence of any IPH was found two years after the index event (42.9% vs. 55.6%; p = 0.008) (Figure 1) Patients already using antiplatelet agents before the index event (n=19) did not show significantly more IPH (52.6% vs. 63.2%, p = 0.50) at follow-up. Patients who did not use platelet aggregation inhibitors before the index event (n=44) and were prescribed medication after the event, showed a significantly higher prevalence of IPH (38.6% vs. 52.3%, p=0.031) at follow-up (Figure 2) Conclusion: Patients who started antiplatelet therapy after the index event show a significant increase in bilateral IPH two years after inclusion, while no significant changes in IPH status were found in the patients that already use antiplatelet therapy before the index event. Future studies are warranted to investigate causal relationships. Disclosure: JE Wildberger reports institutional grants from AGFA, Bard, Bayer, GE, Optimed, Philips, Siemens outside the submitted work; and speakers Bureau: Bayer, Siemens outside the submitted work. This research was performed within the framework of the Center for Translational Molecular Medicine (www.ctmm.nl), project PARISk (grant 01C-202), and supported by the Dutch Heart Foundation. This project has received funding from the European Union Horizon 2020 research and innovation program under the Marie Skłodowska-Curie grant agreement No 722609. ME Kooi and JE Wildberger are supported by Stichting de Weijerhorst. ME Kooi is supported by an Aspasia Grant 2018/SGw/00460457 from NWO. J Hendrikse has received funding from the European Research Council under the European Union's Horizon 2020 Programme (H2020) / ERC grant agreement n°637024. FHBM Schreuder is supported by the Dutch Heart Foundation (2012T077).

Oral Anticoagulant Therapy after Thromboembolectomy: Is it a Good Option in the Nonagenarian Patient?

Introduction - Acute limb ischaemia (ALI) is not infrequent in nonagenarians and surgical thromboembolectomy remains the treatment of choice. However, the management of postoperative ipocoagulative therapy is often troublesome, due to the risk of hemorragic complications versus thromboembolic recurrencies. This study aims to review the postoperative and long term outcome of patients > 90 year-old patients submitted to limb thromboembolectomy with particular attention to the impact of oral anticoagulant therapy (OAT). Methods - A retrospective 10-year analysis (2006-2016) of all consecutive surgical embolectomies for ALI in > 90 year-old patients was carried out. Perioperative (30-day) and long term outcomes were evaluated in terms of death, limb loss, new embolic events (NEE) and major complications, comparing patients with and without OAT. Pre and postoperative International Normalized Ratio (INR) and activated thromboplastin time (aPTT) laboratory values were also collected and reviewed. Results - Over a total of 295 embolectomies for ALI, 62 (21%) were performed (49 lower limbs, 13 upper limbs) in 41 nonagenarian patients, 32 (51.6%) with permanent and 11 (17.7%) with recent atrial fibrillation (FA). Sixteen (25.8%) were under OAT and 31 (50%) under antiplatelet therapy alone. Vascular dementia was significantly associated with postoperative death and major complication rate (42.1% vs 16.6%, p=.05 and 57.9% vs 31%, p=.05, respectively); diabetes was significantly associated with death and limb loss (66.6% vs 20%, p=.03 and 66.6% vs 7.2%, p=.00, respectively); similarly to preoperative antiplatelet therapy (36% vs 12.9% p=.04, 23% vs 3.2%, p=.03, respectively). At a mean follow up of 28+30 months, the overall survival was 52%, freedom from amputation was 87% and freedom from NEE was 69% with no statistically significant correlation with postoperative OAT. Perioperative death was associated with the presence of higher values of INR and aPTT (2.4±1.4 vs 1.2±0.2, p=.01; 2±0.9 vs 1.5±0.5, p=.04, respectively) and similarly, patients who suffered of postoperative major complications had higher values of INR and aPTT (2±1.3 vs 1.3±0.3, p=.00; 1.9±0.9 vs 1.5±0.4, p=.04, respectively). Conversely, INR and aPTT were significantly lower in patients with limb loss (1.1±0.1 vs 1.7±1, p=.00; 1.3±0.2 vs 1.7±0.7, p=.02, respectively). Conclusion - Long term outcome confirms the effectiveness of surgical thromboembolectomy even in patients with a very advanced age. Since high INR and aPTT values are correlated with higher mortality and complication rates, OAT should be carefully administered in these patients. Its role is however preeminent in preventing future limb ischaemia.

Effect of preoperative antiplatelet or anticoagulation therapy on hemorrhagic complications in patients with traumatic brain injury undergoing craniotomy or craniectomy.

Traumatic brain injury (TBI) is common among the elderly, often treated with antiplatelet (AP) or anticoagulation (AC) therapy, creating new challenges in neurosurgery. In contrast to elective craniotomy, in which AP/AC therapy is mostly discontinued, in TBI usually no delay in treatment can be afforded. The aim of this study was to analyze the effect of AP/AC therapy on postoperative bleeding after craniotomy/craniectomy in TBI. Postoperative bleeding rates in patients treated with AP/AC therapy (blood thinner group) and in those without AP/AC therapy (control group) were retrospectively compared. Furthermore, univariate and multivariate analyses were conducted to identify risk factors for postoperative bleeding. Lastly, a proportional Cox regression analysis comparing postoperative bleeding events within 14 days in both groups was performed. Of 143 consecutive patients undergoing craniotomy/craniectomy for TBI between 2012 and 2017, 47 (32.9%) were under AP/AC treatment. No significant difference for bleeding events was observed in univariate (40.4% blood thinner group vs 36.5% control group; p = 0.71) or Cox proportional regression analysis (log rank χ2 = 0.29, p = 0.59). Patients with postoperative bleeding showed a significantly higher mortality rate (p = 0.035). In the univariate analysis, hemispheric lesion, acute subdural hematoma, hematological disease, greater extent of midline shift, and pupillary difference were significantly associated with a higher risk of postoperative bleeding. However, in the multivariate regression analysis none of these factors showed a significant association with postoperative bleeding. Patients treated with AP/AC therapy undergoing craniotomy/craniectomy due to TBI do not appear to have increased rates of postoperative bleeding. Once postoperative bleeding occurs, mortality rates rise significantly.

2224Preoperative dual antiplatelet therapy and early outcomes in patients undergoing coronary artery bypass grafting

Abstract Background Recent evidence suggests that preoperative antiplatelet regimen with aspirin can be safely used for patients scheduled for coronary artery bypass grafting (CABG), aiming to maintain graft patency and reduce ischemic complications at an acceptable bleeding risk. However, little is known regarding the safety and efficacy of preoperative low-dose dual antiplatelet therapy with aspirin combined clopidogrel for CABG patients. Objective To investigate the efficacy and safety of preoperative low-dose dual antiplatelet therapy with aspirin combined clopidogrel for patients receiving elective isolated CABG. Methods We retrospectively reviewed data from patients underwent isolated elective CABG in our single institution from January 2013 to March 2017. Dual antiplatelet therapy was determined as aspirin (100 mg daily) five days and clopidogrel (75 mg daily) three days proximity to the surgery. Propensity score matching was used to generate matched groups from patients taken dual antiplatelet therapy and aspirin alone. The Kaplan–Meier method and the log-rank test were applied to create and examine survival curves. Cox proportional hazards regression was employed to explore the differences in early-term outcomes between the two strategies. The primary outcome was in-hospital major adverse cardiac and cerebrovascular events (MACCEs, including all-cause death, nonfatal MI and nonfatal stroke). The secondary outcomes were perioperative bleeding complications (re-exploration for bleeding and blood products transfusion), and MACCEs at six months after surgery. Results From January 2013 to March 2017, 1102 patients received 100 mg aspirin daily five days prior to CABG, and 295 of them combined clopidogrel (75mg daily). Patients on dual antiplatelet therapy with aspirin combined clopidogrel were more often underwent previously stent implantation (14.2% versus 7.7%), and no significant difference regarding other patient baseline characteristics was observed between the two groups. Propensity score matching created 295 well-matched sets (dual antiplatelet therapy versus aspirin alone). Compared with preoperative aspirin alone, dual antiplatelet therapy was associated with more in-hospital major adverse cardiac and cerebrovascular events (Odds Ratio [OR], 2.59; 95% confidence internal [CI], 1.05–6.39; P=0.039), and also higher rates of perioperative blood products transfusion (47.1% versus 34.6%, OR 1.69, 95% CI, 1.21–2.35, P=0.002). After 6 months' follow-up (median 198 days), there were 25 patients (8.5%) with an event in the dual antiplatelet therapy group and 12 patients (4.1%) with an event in the aspirin alone group (Hazard Ratio [HR], 2.12; 95% CI, 1.06–4.22; P=0.033). MACCEs at 6 months after CABG Conclusions For patients receiving elective isolated CABG, preoperative low-dose dual antiplatelet therapy with aspirin combined clopidogrel may result in increased early major adverse cardiac and cerebrovascular events and more perioperative blood transfusions.