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

Nov 08, 2022 •228 likes •390 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

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 • 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
Management Decisions • Balloon angioplasty? • Thrombectomy? • Repeat stenting? • DES • BMS • Do you image? • IVUS or OCT? • Anticoagulation? • Heparin • Angiomax • IIbIIIa • Cangrelor
Antithrombotic Regimen • Procedural • Heparin • Tirofiban
Antithrombotic Regimen • Post-procedure • Aspirin 81 mg • Ticagrelor 90 mg daily (following 180mg loading dose) • Tirofiban x 4 hours
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)
Day 2 • No further complaints • No evidence active GI bleed via NGT • Aspirin 81 daily via po • Ticagrelor bolus
Day 4 • Hypotension/intubated for airway protection • Hgb 8.2 • Aspirin/Ticagrelor held • Transfused 2units PRBC and platelets
Day 5 • Stable • Repeat EGD with no evidence of active bleeding • Extubated • Asprin restarted • Clopidogrel loading dose given • No evidence of bleeding throughout remainder of hospital course

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