DAPT remains the cornerstone for prevention of acute stent thrombosis status post PCI. In situations that mandate interruption of DAPT with high risk of stent thrombosis (like our patient), alternative treatment strategies must be considered. The use of cangrelor, with an average half-life of 3-6 minutes as a bridge therapy may provide a viable alternative. However, data regarding its use in non-cardiac surgery patients is almost non-existential. Despite paucity of data, our protocol demonstrates successful off-label use of IV cangrelor bridge therapy in a non-cardiac surgery patient. We present a case of 77-year old male on triple therapy (aspirin, apixaban, and ticagrelor) given history of paroxysmal atrial fibrillation and PCI of in-stent restenosis in an ostial RCA with a drug eluting stent one week prior for NSTEMI who presented with acute GI bleed. Apixaban was held and he was diagnosed with stage I colonic adenocarcinoma with immediate surgical resection recommended. Ticagrelor was discontinued 6 days prior to surgery and Cangrelor was started 24 hours after Ticagrelor discontinuation. Daily P2Y12 assays were performed to ensure adequate platelet inhibition and minimize bleeding risk. Cangrelor was titrated to achieve 65-180 PRUs. Cangrelor was stopped 2 hours before surgical incision and reinitiated 2 hours post-op. Ticagrelor was reinitiated 12 hours post-op once there was surgical confidence of adequate hemostasis. A P2Y12 assay was performed 24 hours after Ticagrelor re-initiation to allay concerns for malabsorption post-op. Patient tolerated exploratory laparoscopic colectomy with minimal bleeding and good post-op recovery.
Keywords: Bleeding, Gastrointestinal, Surgery, Antiplatelet, Drug, Stent
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