Abstract: Stent thrombosis is not unusual in a post-operative setting. Use of heparin, aspirin, clopidogrel, and glycoprotein (GP) IIb/IIIa inhibitors in this setting needs to be balanced because of the increased risk of perioperative bleeding. This is of special concern in neurosurgery, where postoperative mass effect from bleeding in a closed space is a serious risk. We describe a unique case of inferior and anterior ST-elevation myocardial infarction in cardiogenic shock during spinal surgery with acute, very late bare-metal stent (BMS) thrombosis in the left anterior descending coronary artery and simultaneous acute thrombotic occlusion of the right coronary artery, treated by primary percutaneous intervention, intra-aortic balloon pump (IABP) support and use of GP IIb/IIIa inhibitor in addition to clopidogrel, aspirin, and heparin with good surgical and cardiac outcome. This case report describes first time use of GP IIb/IIIa inhibitor and IABP with heparin, in a patient just after spinal surgery.
J INVASIVE CARDIOL 2012;24:76-78
Key words: spinal surgery, STEMI, GP IIb/IIIa inhibitor use
It is well known that discontinuation of antiplatelet therapy relatively soon after PCI has significant mortality and morbidity during non-cardiac surgery. In addition to lack of endothelialization, the prothrombotic state of surgery increases the risk of stent thrombosis. Late angiographic stent thrombosis (LAST) has been reported after drug-eluting stent (DES) implantation in 0.35-0.72% of patients who are not on dual antiplatelet therapy or on monotherapy alone.1 There are a few case reports of very late BMS thrombosis at 6 and 8 years2 and 118 months.3 Treatment of perioperative stent thrombosis is challenging because of the perceived increased risk of bleeding associated with use of antiplatelet and anticoagulant agents in this setting. This risk is especially concerning with closed-compartment surgeries like neurosurgery because of a chance of neurological decline due to compression secondary to bleeding. There are even concerns about using chemoprophylaxis for deep vein thrombosis and pulmonary embolism. We report the case of a 58-year-old male with perioperative anterior and inferior ST elevation myocardial infarction (STEMI) with cardiogenic shock during spinal surgery with acute, very late bare-metal stent (BMS) thrombosis in the left anterior descending (LAD) coronary artery, and simultaneous acute thrombotic occlusion of the right coronary artery (RCA), who was treated by primary percutaneous intervention (PPI), intra-aortic balloon pump support (IABP), and use of glycoprotein (GP) IIb/IIIa inhibitor in addition to clopidogrel, aspirin, and heparin with good surgical and cardiac outcome.
A 58-year-old white male with past medical history of hypertension, coronary artery disease, and stent placement to the LAD in 2001 was admitted for elective repeat back surgery for L2-L5 fusion. He had his first back surgery 3 months prior with no cardiac problems and had a negative pharmacological stress test prior to surgery. Aspirin was stopped a week prior and he was given platelets just before surgery. Intra-operatively, the patient developed hypotension with ST elevations on the monitor. Two Jackson-Pratt (JP) drains were placed at the surgical site and surgery was ended. He was kept on ventilator and cardiology was consulted. Postoperative electrocardiogram showed sinus rhythm with extensive anterolateral and inferior ST elevations (Figure 1). He was in cardiogenic shock with a blood pressure of 70/40 mm Hg on multiple vasopressors. He then developed ventricular fibrillation multiple times, requiring defibrillation, and was in slow junctional rhythm with a heart rate of 40-45 bpm. There was an initial concern of bleeding by neurosurgery, but because of hemodynamic instability and grave prognosis he was started on aspirin, heparin, and lidocaine drip and taken to the cardiac catheterization laboratory emergently. A transvenous pacemaker was placed. A Judkins Right 4 guide was used to engage the RCA, which was occluded proximally. Thrombus aspiration was done using a Pronto aspiration catheter (Vascular Solutions, Inc.). Once the flow was established, a 90% lesion was noted in the proximal RCA (Figure 2); this was predilated with a 3.0 x 15 mm Sprinter Legend balloon (Medtronic), then stented with a 3.5 x 15 mm Driver Rx stent (Medtronic) with optimal result and TIMI 3 flow (Figure 3). Angiogram of the left system revealed thrombus in the proximal LAD inside the previous LAD stent (Figure 4). The patient went into ventricular fibrillation again and was resuscitated according to Advanced Cardiac Life Support protocol. He was also started on eptifibatide due to a large amount of clot burden, hemodynamic instability, and concern for delay in effect of clopidogrel. Aspiration thrombectomy was performed in LAD with a Pronto aspiration catheter, and flow established in the LAD with some distal embolization. Predilatation of the lesion before and in the proximal part of the stent was done with a 3.5 x 12 Sprinter Legend balloon and this lesion was then stented with a 4 x 9 mm Driver Rx stent (Figure 5). An IABP was placed for hemodynamic support and due to recurrent ventricular tachycardia. He was started on clopidrogel and eptifibatide infusion was continued for 6 hours. Postcoronary intervention troponin peaked at 369 ng/mL and hemoglobin was stable at 12.6. There was worsening of renal function and elevation of liver enzymes secondary to cardiogenic shock. Transthoracic echocardiogram (TTE) revealed an ejection fraction of 30-35% with severe hypokinesia of septal, apical, and anterior walls. The patient continued to improve and was weaned off vasopressor support. Transvenous pacer was removed on postintervention day 3. INR was elevated at the range of 2.7 and he was given fresh frozen plasma and vitamin K before discontinuation of IABP. During this time, the patient had initially bloody then serosanginous drainage in the two JP drains, which was not unusually excessive. JP drains were removed on postoperative day 5. The patient had a prolonged hospitalization, but did not suffer any neurological damage and liver and renal functions returned to baseline. The patient continued to do well at 1 and 6 months after discharge. Repeat TTE done at 6 months showed improvement in wall motion abnormalities and ejection fraction of 45-50%.
Acute occlusion of two major vessels is not a common event after surgery and carries a very high mortality. The presentation of our patient was unique as two major vessels were occluded including very late stent thrombosis (VLST) of a BMS. Cardiogenic shock necessitated use of IABP, triple antiplatelet therapy, and anticoagulation because of high clot burden in this spinal surgery patient, which added to the challenging issues in the management of this case as discussed below.
VLST of BMS in a perioperative setting. Stent thrombosis in the perioperative period has been frequently reported in DES,4,5 but reports of BMS thrombosis in perioperative setting are rare. VLST has also been considered a rare complication with BMS. However, a recent study has shown that although more common with DES, VLST after primary PCI with BMS for STEMI can occur with relatively high frequency for up to 11 years. In this single-center study of about 1400 patients, BMS were associated with VLST of 0.6% per year compared to 1.9% for DES.6 In a study that looked at the mechanism of VLST, stent malapposition was unique to DES-related VLST, whereas disease progression with neointimal rupture was more common in BMS patients.7 In our patient, the post-surgical prothrombotic state with withdrawal of antiplatelet therapy and platelet transfusion were likely responsible for STEMI which involved the BMS as well as the native vessel.
Effect of IABP on spinal arteries. Although there was a compelling indication for use of IABP in our patient, there was a concern for spinal cord infarction in a post-spinal surgery patient. There was no literature that addressed the use of IABP in such a scenario. However, in a study from Benchmark Counterpulsation Outcomes Registry by Stone et al, major IABP-related complications in patients with acute myocardial infarction were relatively infrequent (2.7%) and the incidence of bowel, renal, or spinal cord infarction was only 0.1%.8 Our patient did not develop any complication after a 3-day use of IABP.
Concomitant use of aspirin, clopidogrel, GP IIb/IIIA inhibitor, and heparin in a post-surgical patient and risk of bleeding after spinal surgery. There are no studies that directly address the use of triple antiplatelet therapy with heparin in the setting of perioperative STEMI. Risk of bleeding after spinal surgery in patients receiving antiplatelet agents and anticoagulants has only recently come under review and there are no randomized control trials. In a recent review based on analysis of over 400 abstracts, the reported incidences of clinically relevant postoperative epidural hematoma are low, ranging from 0% to 1%, although many surgeons perceive the risk to be higher. Aspirin has been implicated in bleeding associated with neurosurgery;9,10 however, the exact risk for this complication is not known. In a single-center retrospective review of patients who underwent spinal surgery over a 10-year period, multilevel procedures (P=.037) and the presence of a preoperative coagulopathy (P<.001) were significant risk factors for perioperative bleeding. Age, body mass index, perioperative durotomies, and postoperative drains were not statistically significant risk factors.11 In another study that addressed the risk of anticoagulation for thromboprophylaxis, bleeding complications occurred rarely with the use of anticoagulation and risk of major bleeding ranging from 0.0% to 4.3% across several types of anticoagulants, whereas postoperative hematoma was reported in only 10 of 2507 patients.12 As there is no direct evidence, use of antiplatelet agents and anticoagulants in patient with spinal surgery is a contentious issue in routine circumstances, but the low incidence of these complications justifies such use in acute situations like STEMI, albeit at an increased risk of bleeding.
Withdrawal of antiplatelet therapy can have catastrophic consequences even in patients with BMS who are still at a risk of stent thrombosis, albeit at a lower risk than those with DES. Aspirin, clopidogrel, and short-term use of eptifibatide and IABP was safe in our patient in the perioperative setting of spinal surgery.
- Ong AT, McFadden EP, Regar E, de Jaegere PP, van Domburg RT, Serruys PW. Late angiographic stent thrombosis (LAST) events with drug-eluting stents. J Am Coll Cardiol. 2005;45(12):2088-2092.
- Lemesle G, Pinto Slottow TL, Waksman R. Very late stent thrombosis after bare-metal stent implantation: case reports and review of the literature. J Invasive Cardiol. 2009;21(2):E27-E32.
- Sengül C, Erdogan T, Dindar I. Very late bare metal stent thrombosis: the role of restenosis. Turk Kardiyol Dern Ars. 2010;38(4):282-284.
- McFadden EP, Stabile E, Regar E, et al. Late thrombosis in drug-eluting coronary stents after discontinuation of antiplatelet therapy. Lancet. 2004;364(9444):1519-1521.
- De Souza DG, Baum VC, Ballert NM. Late thrombosis of a drug-eluting stent presenting in the perioperative period. Anesthesiology. 2007;106(5):1057-1059.
- Brodie B, Pokharel Y, Fleishman N, et al. Very late stent thrombosis after primary percutaneous coronary intervention with bare-metal and drug-eluting stents for ST-segment elevation myocardial infarction: a 15-year single-center experience. JACC Cardiovasc Interv. 2011;4(1):30-38.
- Lee CW, Kang SJ, Park DW, et al. Intravascular ultrasound findings in patients with very late stent thrombosis after either drug-eluting or bare-metal stent implantation. J Am Coll Cardiol. 2010;55(18):1936-1942.
- Stone GW, Ohman EM, Miller MF, et al. Contemporary utilization and outcomes of intra-aortic balloon counterpulsation in acute myocardial infarction — the benchmark registry. J Am Coll Cardiol. 2003;41(11):1940-1945.
- Merriman E, Bell W, Long DM. Surgical postoperative bleeding associated with aspirin ingestion. J Neurosurg. 1979;50(5):682-684.
- Palmer JD, Sparrow OC, Iannotti F. Postoperative hematoma: a 5-year survey and identification of avoidable risk factors. Neurosurgery. 1994;35(6):1061-1065.
- Kou J, Fischgrund J, Biddinger A, Herkowitz H. Risk factors for spinal epidural hematoma after spinal surgery. Spine. 2002;27(15):1670-1673.
- Cheng JS, Arnold PM, Anderson PA, Fischer D, Dettori JR. Anticoagulation risk in spine surgery. Spine. 2010;35(9 Suppl):S117-S124.
From the 1Division of Cardiology and 2Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, Louisiana.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted September 2, 2011, provisional acceptance given October 12, 2011, final version accepted October 19, 2011.
Address for correspondence: Saurabh Rajpal, MBBS, MD, Chief Resident, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, 1501 Kings Hwy, Shreveport LA, 71103. Email: firstname.lastname@example.org