Case Presentation The conundrum of high bleeding and ischemic risk - - PowerPoint PPT Presentation

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Nov 08, 2022 228 likes •391 views

Case Presentation The conundrum of high bleeding and ischemic risk David L. Fischman MD FSCAI Thomas Jefferson University Hospital May 21, 2019 Disclosures None A Call from the PACU Clinical Presentation 79 year-old female with hx CAD

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Case Presentation The conundrum of high bleeding and ischemic risk

David L. Fischman MD FSCAI Thomas Jefferson University Hospital May 21, 2019

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Disclosures

None

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A Call from the PACU

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Clinical Presentation

79 year-old female with hx CAD
PCI (stent) of RCA 11mos ago
Unknown indication
Unknown stent type (BMS vs DES)
s/p submucosal dissection of adenocarcinoma of stomach
35 mm mass
Clip and sutured
Medications included daily aspirin (81mg) and atorvastatin
Aspirin missed only morning of EGD

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Management Decisions

Balloon angioplasty?
Thrombectomy?
Repeat stenting?
DES
BMS
Do you image?
IVUS or OCT?
Anticoagulation?
Heparin
Angiomax
IIbIIIa
Cangrelor

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Antithrombotic Regimen

Procedural
Heparin
Tirofiban

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Antithrombotic Regimen

Post-procedure
Aspirin 81 mg
Ticagrelor 90 mg daily (following 180mg

loading dose)

Tirofiban x 4 hours

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Day 0-1

c/o abdominal pain/nausea/vomiting 2.5hrs post

procedure

Hgb 13.8 9.2
Tirofiban d/c’d
Cangrelor and aspirin (PR)

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Day 2

No further complaints
No evidence active GI bleed via NGT
Aspirin 81 daily via po
Ticagrelor bolus

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Day 4

Hypotension/intubated for airway protection
Hgb 8.2
Aspirin/Ticagrelor held
Transfused 2units PRBC and platelets

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Day 5

Stable
Repeat EGD with no evidence of active bleeding
Extubated
Asprin restarted
Clopidogrel loading dose given
No evidence of bleeding throughout remainder
f hospital course