Case reports of two patients with malignant disease, scheduled for surgery after recent coronary stenting.
Keywords: coronary stent, thrombosis, bleeding.
Case Report 1
77-year-old male was diagnosed with gastric cancer. Because of stable angina, coronary angiography was performed and it was discovered that the patient had distal stenosis of left anterior descending artery (LAD), which was stented with bare metal stent (BMS). Antiplatelet therapy with acetylsalicylic acid (ASA) and clopidogrel was started. After the procedure, tumor caused continuous bleeding. Endoscopic control of bleeding was unsuccessful. Consequently, clopidogrel was canceled six days after stenting and the patient was scheduled for surgery. Restenosis occurred after one week but was resolved with three drug-eluting stents (DES). Up until the day of surgery, the patient received intravenous infusion of cangrelor. Total gastrectomy was performed without complications. The patient was administered antiplatelet therapy with ticagrelor on the first day following the surgery. On the second day, the patient suffered ST-segment elevation myocardial infarction (STEMI). Thrombosis of DES stent in LAD was confirmed and stent was reopened with balloon angioplasty. Subsequently, five DES stents were placed in LAD. Therapy with ticagrelor was carried on. On the ninth day, following myocardial infarction, the patient was transferred from high dependency unit to normal ward for further rehabilitation. Two days later, he suffered cardiac arrest, resuscitation was unsuccessful. The autopsy did not confirm any stent thrombosis.
Case Report 2
60-year-old male was scheduled for video-assisted thoracoscopic resection (VATS) of right upper lobe due to lung carcinoma. He had suffered STEMI of anterior wall four months earlier. 3-vessel disease was discovered and DES stents inserted in LAD, left circumflex artery (LCX) and right coronary artery (RCA). He was treated with ASA and clopidogrel. Due to high risk for life threatening stent thrombosis, this treatment was continued perioperatively. During the surgery the patient was stable, blood loss was minimal. He was discharged from hospital on the fifth postoperative day.
Surgery in patients with malignant disease and recent coronary stenting can rarely be postponed after recommended dual antiplatelet therapy had been completed. Preoperatively, the risk of surgical bleeding on antiplatelet therapy against life threatening stent thrombosis due to premature discontinuation should be discussed with surgeon, cardiologist and anaesthesiologist.
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