Clopidogrel Poses Little Bleeding Risk During Thoracic Surgery
Major Finding: Thirty-three patients who underwent thoracic surgery while on dual antiplatelet therapy with clopidogrel and aspirin generally had no increased bleeding risk, compared with thoracic surgery patients withdrawn from these drugs.
Data Source: Prospective, consecutive series of 33 patients at one U.S. center during January 2009-April 2010 who represented the full range of thoracic surgery procedures.
Disclosures: Dr. Cerfolio said that he and his associates had no relevant disclosures.
TORONTO – Thoracic surgeons can safely perform virtually their entire repertoire of operations in patients on continuous dual antiplatelet therapy with clopidogrel and aspirin, based on the outcomes of a consecutive series of 33 patients at one U.S. center.
Redo thoracotomy stood out as the only exception, because of the pleural bleeding threat it poses when adhesions are removed. For these patients, surgeons should maintain clopidogrel (Plavix) but withdraw aspirin starting a week before surgery and then resume the aspirin 1-3 days postoperatively, Dr. Robert J. Cerfolio said at the annual meeting of the American Association for Thoracic Surgery.
Dr. Cerfolio said that he has no reservations about performing any other type of thoracic surgery on patients who have both clopidogrel and aspirin on board. “I’m convinced. We’ve now done just about every procedure on the chest” in these initial 33 patients, including open and robotic lung lobectomies, Ivor Lewis esophagogastrectomy, video-assisted thoracic surgery, mediastinoscopy, sternotomy to remove a 9 cm thymic tumor, and primary and redo thoracotomy, Dr. Cerfolio, professor and chief of thoracic surgery at the University of Alabama, Birmingham.
The patients underwent surgery at the University of Alabama during January 2009-April 2010. Their age ranged from 36 to 88 years, and 85% were men. They had been on antiplatelet medications for an average of 5 months before surgery; 21 of the 33 patients were on aspirin and clopidogrel because of a coronary stent. The only procedure that triggered any significant bleeding was the redo thoracotomy, which led to both operative and postoperative bleeding.
Having performed procedures in 25 patients on clopidogrel, Dr. Cerfolio said he was confident about safety. “But I went too fast in taking out the adhesions, and the pleura started bleeding. The biggest bleeding problem is always the pleura,” he said. One of these patients bled 1,000 cc, the other bled 1,400 cc, so Dr. Cerfolio performed his next two redo thoracotomies more slowly and carefully to avoid extensive bleeding. He also took the third and fourth redo thoracotomy patients off the aspirin.
“I called the head of cardiology and the head of interventional cardiology [at the University of Alabama]. They both said stop the aspirin and continue clopidogrel,” he said in an interview.
The issue of maintaining clopidogrel in patients who need thoracic surgery is increasingly important because the number of patients who fit this profile continues to grow, he added.
Before starting this series, Dr. Cerfolio and his associates had routinely withdrawn their thoracic surgery patients from both clopidogrel and aspirin a week before surgery. Because of concern that this step could potentially trigger thrombus formation in patients who had received a drug-eluting coronary stent, patients at the University of Alabama awaiting thoracic surgery and needing percutaneous coronary intervention had received bare-metal stents. In addition, the surgeons had delayed thoracic surgery for 6-8 weeks following stent placement to allow a full course of clopidogrel and aspirin before withdrawal for surgery. Consequently, patient care was suboptimal because they received bare-metal instead of drug-eluting coronary stents and because their surgery was delayed.
“Most of the dilemma was based on the surgical dogma that you could not perform surgery on patients on clopidogrel,” Dr. Cerfolio said.
The researchers compared their surgical and postoperative outcomes with those of 132 control patients culled by matched propensity scores from more than 11,000 historical controls who underwent thoracic surgery in Birmingham off of dual antiplatelet therapy. Dr. Cerfolio cautioned that this represented a limitation of the study because the relatively limited pool of potential controls for matching meant that some controls might not have perfectly matched the cases. Despite this caveat, the cases and controls showed good matching for factors including smoking history, coronary artery disease, diabetes, presence of coronary stents, and preoperative chemotherapy.
Among the 29 cases who did not undergo redo thoracotomy none had significant bleeding, compared with one case of bleeding among 120 control patients. The two significant bleeding cases in the four patients who underwent redo thoracotomy while on aspirin and clopidogrel (two patients) or clopidogrel alone (two patients) compared with no significant bleeds among 12 control patients who underwent redo thoracotomies while off of both aspirin and clopidogrel. The rates of morbidity, mortality, and major adverse coronary events were similar among the cases and controls.
A subgroup analysis focused on 21 cases and 43 controls who had coronary stents at the time of their thoracic surgery. Their overall morbidity and mortality rates were similar, but the rate of major coronary events, one (5%) in the clopidogrel group and five (12%) in the group taken off clopidogrel, suggested a trend toward better protection when clopidogrel continued during surgery.
