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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