Perioperativer Umgang mit Antikoagulanzien und Thrombozytenaggregationshemmern in der Thoraxchirurgie

Zusammenfassung

Der perioperative Umgang mit antikoagulatorischen Substanzen in der Thoraxchirurgie ist ein „zweischneidiges Schwert“: Das Bestreben, einerseits das thrombembolische Risiko im arteriellen und venösen Gefäßsystem zu minimieren, steht im Gegensatz zu dem Ziel der intra- und postoperativen Blutungsvermeidung. Aufgrund dispositioneller Risikofaktoren wie Nikotinabusus bieten die thoraxchirurgischen Patienten häufig kardiovaskuläre Komorbiditäten, die eine antikoagulative oder antithrombozytäre Therapie notwendig machen. In der Thromboseprophylaxe, im perioperativen Umgang mit Vitamin-K-Antagonisten und Plättchenaggregationshemmern hat sich die Erstellung von individuellen Risikoprofilen mit Einteilung in verschiedene Risikoklassen bewährt. Mit deren Hilfe können Behandlungspläne zu perioperativer antikoagulatorischer Therapie entworfen werden, die den Patienten bestmöglich auf dem Grat zwischen Blutung und Thrombembolie führen. Für die neuen oralen Antikoagulanzien existieren bislang zu wenig Daten, um evidenzbasierte Empfehlungen zur perioperativen Therapieumstellung zu geben. Algorithmen werden vorgeschlagen, welche die verschiedenen Facetten antikoagulatorischer Therapie berücksichtigen.

Abstract

The perioperative use of anticoagulants in general thoracic surgery can be considered to be a “two-edged sword”: the goal to minimise the risk of a thromboembolic episode is contrary to the ongoing effort of the surgeon to minimise the risk of intra- and postoperative blood loss. Dispositional factors such as excessive tobacco use are common for thoracic surgery patients and often lead to cardiovascular comorbidity which necessitates the use of anticoagulants or antiplatelet drugs. For deep venous thrombosis prophylaxis and for the indication and use of vitamin K antagonists or antiplatelet drugs it is proven in the literature that the risk profile of the patient and his/her classification in the appropriate risk group are of major importance. Through the individual risk profile of the patient it is possible to plan the appropriate perioperative anticoagulant therapy which will safely assist the surgeon and his/her patient during the peri- and postoperative phase on the knife-edge between blood loss and eminent thromboembolism. Unfortunately there are not enough existing data and published literature for evidence-based guidelines referring to the correct perioperative management for the new oral anticoagulants. Management algorithms are being recommended according to the multiple aspects of anticoagulant-treatment.

Schlüsselwörter

Thromboseprophylaxe - Vitamin-K-Antagonisten - Thrombozytenaggregationshemmung - perioperatives Bridging - Thoraxchirurgie - NOAK

Key words

thromboprophylaxis - vitamin K antagonists - antiplatelet therapy - perioperative bridging - thoracic surgery - NOAC

• Literatur

• 1 Boffa DJ, Allen MS, Grab JD et al. Data from The Society of Thoracic Surgeons General Thoracic Surgery database: the surgical management of primary lung tumors. J Thorac Cardiovasc Surg 2008; 135: 247-254
• 2 Kalweit G, Huwer H, Volkmer I et al. Pulmonary embolism: a frequent cause of acute fatality after lung resection. Eur J Cardiothorac Surg 1996; 10: 242-246
• 3 Kelishadi R, Poursafa P. A review on the genetic, environmental, and lifestyle aspects of the early-life origins of cardiovascular disease. Curr Probl Pediatr Adolesc Health Care 2014; 44: 54-72
• 4 Shiono S, Abiko M, Sato T. Postoperative complications in elderly patients after lung cancer surgery. Interact Cardiovasc Thorac Surg 2013; 16: 819-823
• 5 Horlander KT, Mannino DM, Leeper KV. Pulmonary embolism mortality in the United States, 1979–1998: an analysis using multiple-cause mortality data. AMA Arch Intern Med 2003; 163: 1711-1717
• 6 Cade JF, Clegg EA, Westlake GW. Prophylaxis of venous thrombosis after major thoracic surgery. Aust N Z J Surg 1983; 53: 301-304
• 7 Azorin JF, Regnard JF, Dahan M et al. [Efficacy and tolerability of fraxiparine in the prevention of thromboembolic complications in oncologic thoracic surgery]. Ann Cardiol Angeiol (Paris) 1997; 46: 341-347
• 8 Ziomek S, Read RC, Tobler HG et al. Thromboembolism in patients undergoing thoracotomy. Ann Thorac Surg 1993; 56: 223-226
• 9 Nagahiro I, Andou A, Aoe M et al. Intermittent pneumatic compression is effective in preventing symptomatic pulmonary embolism after thoracic surgery. Surg Today 2004; 34: 6-10
• 10 Gould MK, Garcia DA, Wren SM et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (Suppl. 02) S227-S277
• 11 AWMF-Leitlinie Prophylaxe der venösen Thromboembolie (VTE). Im Internet: http://www.awmf.org/Leitlinien/detail/ll/003-001.html Stand: 2010
• 12 Detterbeck FC. Diagnosis and Treatment of Lung Cancer: An Evidence-Based Guide for the practicing Clinician. Philadelphia, PA: Saunders WB; 2001
• 13 Huo MH, Muntz J. Extended thromboprophylaxis with low-molecular-weight heparins after hospital discharge in high-risk surgical and medical patients: a review. Clin Ther 2009; 31: 1129-1141
• 14 Prevention of fatal postoperative pulmonary embolism by low doses of heparin. An international multicentre trial. Lancet 1975; 2: 45-51
• 15 National Collaborating Centre for Acute Care. Venous Thromboembolism: Reducing the Risk of Venous Thromboembolism (Deep Vein Thrombosis And Pulmonary Embolism) in Patients Admitted to Hospital. London, England: NICE; 2010
• 16 Haas S, Wolf H, Kakkar AK et al. Prevention of fatal pulmonary embolism and mortality in surgical patients: a randomized double-blind comparison of LMWH with unfractionated heparin. Thromb Haemost 2005; 94: 814-819
• 17 Warkentin TE, Greinacher A, Koster A et al. Treatment and prevention of heparin-induced thrombocytopenia: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133 (Suppl. 06) S340-S380
• 18 Rühl H, Pötzsch B. Präinterventionelles Hämostasemanagement. Klinikarzt 2014; 43: 36-41
• 19 Roth GJ, Majerus PW. The mechanism of the effect of aspirin on human platelets. I. Acetylation of a particulate fraction protein. J Clin Invest 1975; 56: 624-632
• 20 Cerskus AL, Ali M, Davies BJ et al. Possible significance of small numbers of functional platelets in a population of aspirin-treated platelets in vitro and in vivo. Thromb Res 1980; 18: 389-397
• 21 Douketis JD, Spyropoulos AC, Spencer FA et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (Suppl. 02) S326-S350
• 22 Poldermans D, Bax JJ, Boersma E et al. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: the Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). Eur J Anaesthesiol 2010; 27: 92-137
• 23 Devereaux PJ, Mrkobrada M, Sessler DI et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med 2014; 370: 1494-1503
• 24 Bonzel T, Erbel R, Hamm CW et al. [Percutaneous coronary interventions (PCI)]. Clin Res Cardiol 2008; 97: 513-547
• 25 Iakovou I, Schmidt T, Bonizzoni E et al. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA 2005; 293: 2126-2130
• 26 Cerfolio RJ, Minnich DJ, Bryant AS. General thoracic surgery is safe in patients taking clopidogrel (Plavix). J Thorac Cardiovasc Surg 2010; 140: 970-976
• 27 Voltolini L, Rapicetta C, Luzzi L et al. Lung resection for non-small cell lung cancer after prophylactic coronary angioplasty and stenting: short- and long-term results. Minerva Chir 2012; 67: 77-85
• 28 Ceppa DP, Welsby IJ, Wang TY et al. Perioperative management of patients on clopidogrel (Plavix) undergoing major lung resection. Ann Thorac Surg 2011; 92: 1971-1976
• 29 Robinson M, Healey JS, Eikelboom J et al. Postoperative low-molecular-weight heparin bridging is associated with an increase in wound hematoma following surgery for pacemakers and implantable defibrillators. Pacing Clin Electrophysiol 2009; 32: 378-382
• 30 Birnie DH, Healey JS, Wells GA et al. Pacemaker or defibrillator surgery without interruption of anticoagulation. N Engl J Med 2013; 368: 2084-2093
• 31 Siegal D, Yudin J, Kaatz S et al. Periprocedural heparin bridging in patients receiving vitamin K antagonists: systematic review and meta-analysis of bleeding and thromboembolic rates. Circulation 2012; 126: 1630-1639
• 32 Katholi RE, Nolan SP, McGuire LB. Living with prosthetic heart valves. Subsequent noncardiac operations and the risk of thromboembolism or hemorrhage. Am Heart J 1976; 92: 162-167
• 33 Sie P, Samama CM, Godier A et al. Surgery and invasive procedures in patients on long-term treatment with direct oral anticoagulants: thrombin or factor-Xa inhibitors. Recommendations of the Working Group on Perioperative Haemostasis and the French Study Group on Thrombosis and Haemostasis. Arch Cardiovasc Dis 2011; 104: 669-676
• 34 Blech S, Ebner T, Ludwig-Schwellinger E et al. The metabolism and disposition of the oral direct thrombin inhibitor, dabigatran, in humans. Drug Metab Dispos 2008; 36: 386-399
• 35 Eriksson BI, Quinlan DJ, Weitz JI. Comparative pharmacodynamics and pharmacokinetics of oral direct thrombin and factor xa inhibitors in development. Clin Pharmacokinet 2009; 48: 1-22
• 36 van Ryn J, Stangier J, Haertter S et al. Dabigatran etexilate – a novel, reversible, oral direct thrombin inhibitor: interpretation of coagulation assays and reversal of anticoagulant activity. Thromb Haemost 2010; 103: 1116-1127
• 37 Marlu R, Hodaj E, Paris A et al. Effect of non-specific reversal agents on anticoagulant activity of dabigatran and rivaroxaban: a randomised crossover ex vivo study in healthy volunteers. Thromb Haemost 2012; 108: 217-224
• 38 Giebl A, Gurtler K. [New oral anticoagulants in perioperative medicine]. Anaesthesist 2014; 63: 347-364
• 39 Schulman S, Bijsterveld NR. Anticoagulants and their reversal. Transfus Med Rev 2007; 21: 37-48
• 40 Bijsterveld NR, Moons AH, Boekholdt SM et al. Ability of recombinant factor VII a to reverse the anticoagulant effect of the pentasaccharide fondaparinux in healthy volunteers. Circulation 2002; 106: 2550-2554
• 41 Pernod G, Albaladejo P, Godier A et al. Management of major bleeding complications and emergency surgery in patients on long-term treatment with direct oral anticoagulants, thrombin or factor-Xa inhibitors: proposals of the working group on perioperative haemostasis (GIHP) – March 2013. Arch Cardiovasc Dis 2013; 106: 382-393
• 42 Levi M, Eerenberg E, Kamphuisen PW. Bleeding risk and reversal strategies for old and new anticoagulants and antiplatelet agents. J Thromb Haemost 2011; 9: 1705-1712
• 43 Leithauser B, Zielske D, Seyfert UT et al. Effects of desmopressin on platelet membrane glycoproteins and platelet aggregation in volunteers on clopidogrel. Clin Hemorheol Microcirc 2008; 39: 293-302
• 44 Geerts WH, Bergqvist D, Pineo GF et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133 (Suppl. 06) 381S-453S