Urgent or Emergent Coronary Revascularization Using Bilateral Internal Thoracic Artery after Previous Clopidogrel Antiplatelet Therapy

Abstract

Background: Clopidogrel application before diagnostic or therapeutical percutaneous coronary intervention has become the standard for stent thrombosis prevention. Irreversible platelet inhibition causes increasing bleeding complications if urgent coronary artery bypass grafting is necessary. This study evaluates the effect on bleeding complications of clopidogrel in urgent CABG using bilateral internal thoracic artery (ITA) and saphenous veins in all patients. Methods: We retrospectively analyzed 128 patients (operated between January 2000 and September 2002) undergoing urgent or emergent CABG using both ITAs, and compared 64 patients with previous clopidogrel and aspirin application (within 5 days) to 64 patients without clopidogrel. We evaluated chest tube output, re-exploration rate and necessity of blood products, ventilation time and ICU stay. Results: Both groups were comparable in age, gender, number of performed anastomoses (mean 4/patient). Chest tube output (24 h) was higher in the clopidogrel group at 977 ± 628 ml vs. 788 ± 389 ml (p = 0.046), as was re-exploration rate with 7.81 % (5 of 64) vs. 0 % (0 of 64) (p < 0.005). The number of blood products amounted to 2.7 ± 1.9 U in the clopidogrel group vs. 1.9 ± 1.6 U (p = 0.013) for red cells, 0.05 ± 0.9 U vs. 0.03 ± 0.25 (p = 0.0003) for platelets, and 0.5 ± 1.3 U vs. 0.2 ± 1.0 U (p = 0.14) for fresh frozen plasma. Mechanical ventilation time was 11.9 ± 9.7 h vs. 9.6 ± 5.9 h (p = 0.10), ICU stay 32.6 ± 22.1 h vs. 27.8 ± 18.2 h (p = 0.19). Conclusions: Previous application of clopidogrel in combination with aspirin before urgent CABG induces increased chest tube output, re-exploration rate and necessity of blood products, especially platelets. Nevertheless, routine use of both ITAs in patients after clopidogrel exposure can be performed with acceptable bleeding complications.

Clopidogrel and CABG

References

• 1 Schömig A, Neumann F J, Kastrati A. et al . A randomized comparison of antipletelet and anticoagulant therapy after the placement of coronary artery stents.  N Engl J Med. 1996;  334 1084-1089
• 2 Leon M B, Baim D S, Popma J J. et al . A clinical trial comparing three antithrombotic-drug regimens after coronary artery stenting. Stent Anticoagulation Restenosis Study Investigators.  N Engl J Med. 1998;  339 1665-1671
• 3 Bennett C L, Weinberg P D, Rozenberg-Ben-Dror K. et al . Thrombotic thrombocytopenic purpura associated with ticlopidine: a view of 60 cases.  Ann Intern Med. 1998;  128 541-544
• 4 Herbert J M, Frehel D, Vallee E. et al . Clopidogrel a novel antiplatelet and antithrombotic agent.  Cardiovasc Drug Rev. 1993;  11 180-198
• 5 Harker L A, Boissel J P, Pilgrim A J. et al . Comperative safety and tolerability of clopidogrel and aspirin: results from CAPRIE. Clopidogrel versus aspirin in patients at risk of ischemic events.  Drug Safety. 1999;  21 325-353
• 6 Taniuchi M, Kurz H I, Lasala J M. Randomized comparison of ticlopidine and clopidogrel after intracoronary stent implantation in a broad patient population.  Circulation. 2001;  104 539-543
• 7 Hankey G J, Sudlow C IM, Dunbabin D W. Thienopyridines or aspirin to prevent stroke and other serious vascular events in patients at high risk of vascular disease? A systematic review of the evidence from randomized trials.  Stroke. 2000;  31 1779-1784
• 8 CAPRIE Steering Committee . A randomized, blinded trial of clopidogrel versus aspirin in patients at risk of ischemic events.  (CAPRIE). Lancet. 1996;  348 1329-1339
• 9 Bertrand M E, Rupprecht H-J, Urban P, Gershlick A H, for the classic investigators. Double-blind study of the safety of clopidogrel with and without a loading dose in combination with aspirin compared with ticlopidine in combination with aspirin after coronary stenting: the Clopidogrel Aspirin Stent International cooperative study (CLASSICS).  Circulation. 2000;  102 624-629
• 10 Muller C, Buttner H J, Petersen J, Rosenkamm H. A randomized comparison of clopidogrel and aspirin versus ticlopidine and aspirin after the placement of coronary artery stents.  Circulation. 2000;  101 590-593
• 11 Yusuf S, Zhao F, Mehta S R, Chrolavicius S, Tognoni G, Fox K K. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation.  N Engl J Med. 2001;  435 494-502
• 12 Lytle B W, Cosgrove D M, Loop F D, Borsh J, Goormastic M. Taylor PC. Perioperative risk of bilateral internal mammary artery grafting: analysis of 500 cases from 1971-1984.  Circulation. 1986;  74 (Suppl III) 37-41
• 13 Gansera B, Günzinger R, Angelis I. et al . End of the millenium - end of single thoracic artery graft. Two thoracic arteries - standard for the next millenium? Early clinical results and analysis of risk factors in 1.487 patients with bilateral internal thoracic artery grafts.  Thorac Cardiovasc Surg. 2001;  49 10-15
• 14 Klein M, Keith P R, Dauben H P. et al . Aprotinin counterbalances and increased risk of perioperative hemorrhage in CABG patients pretreated with aspirin.  Eur J Cardiothorac Surg. 1998;  14 360-366
• 15 Geiger J, Brich J, Honig-Leidl P. et al . Specific impairment of human platelet P₂YAC ADP receptor mediated signaling by the antiplatelet drug clopidogrel.  Arterioscler Thromb Vasc Biol. 1999;  19 2007-2011
• 16 Herbert J M, Savi P, Maffrand J P. Biochemical and pharmacological properties of clopidogrel: A new ADP receptor antagonist.  Eur Heart J. 1999;  Suppl A A31-A40
• 17 Savcic M, Hauert J, Bachmann F, Wyld P J, Geudelin B, Cariou R. Clopidogrel loading dose regimes: Kinetic profile of pharmodynamic response in healthy Subjects.  Semin Thromb Hemost. 1999;  25 (Suppl 2) 15-19
• 18 Yende S, Wunderink R G. Effect of clopidogrel on bleeding after coronary artery bypass surgery.  Crit Case Med. 2001;  29 2271-2275
• 19 Le Narz L A. Coronary artery bypass graft in abciximab-treated patients.  Ann Thorac Surg. 2000;  70 38-42
• 20 Hongo R H, Ley J, Dick S E. et al . The effect of clopidogrel in combination with aspirin undergiven before coronary artery bypass grafting.  IACC. 2002;  40 231-237
• 21 Braunwald E, Antman E M, Beasley J W. et al . ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients with Unstable Angina).  J Am Coll Cardiol. 2000;  36 970-1062