Operable gastric cancer diagnosed soon after implantation of a coronary drug-eluting stent: how to manage?

Summary

Background

An increasing number of patients receive dual antiplatelet therapy following percutaneous coronary interventions. The management of these patients is controversial when urgent noncardiac surgery is required, considering the serious cardiological consequences if such drugs are withdrawn and a high risk of bleeding if they are continued. “Bridging” antiplatelet therapy with tirofiban, a short-acting glycoprotein IIb/IIIa receptor blocker, was used to manage a patient recently implanted with a drug-eluting stent and still on dual antiplatelet therapy, who underwent laparoscopic gastrectomy for gastric carcinoma.

Methods

Therapy with prasugrel was discontinued 5 days before the surgery and intravenous infusion of tirofiban was started at a dose of 0.4 mg Kg^{−  1} min^{−  1} over 30 min, followed by 0.1 mg Kg^{−  1} min^{−  1}. The infusion was stopped 6 h before the surgery. Two hours after the surgical procedure, the same treatment schedule with tirofiban already given preoperatively, including the 30 min bolus, was applied. Prasugrel therapy was resumed 180 h after the surgery.

Results

The postoperative course was uneventful. No bleeding or thrombotic events occurred, and the patient was safely discharged home 2 weeks after the surgical procedure.

Conclusions

There is a lack of precise guidelines for patients recently implanted with drug-eluting stents. A multidisciplinary approach and close collaboration among surgeons, anesthesiologists and cardiologists is required, especially when the surgical procedure cannot be postponed. The “bridging” pharmacological protocol was safe and effective after laparoscopic gastrectomy for carcinoma