Despite the common clinical practice among surgeons to discontinue their patients' anti-platelet therapy prior to surgery, a recent study of patients undergoing carotid endarterectomy (CEA) indicated that this practice may be unnecessary. The study will be published in the December issue of the Annals of Vascular Surgery.
The use of clopidogrel (Plavix, Bristol-Myers Squibb/Sanofi-Aventis), an antiplatelet agent prescribed for patients with acute myocardial infarction, recent stroke or peripheral arterial disease, continues to rise with U.S. sales of $3.9 billion in 2007, wrote the authors. As a result, the researchers sought to examine outcomes related to antiplatelet therapy in patients undergoing CEA, which is a surgical procedure that removes plaque from the carotid arteries in the neck to prevent stroke.
"Most surgeons choose to discontinue their patients' use of anti-platelets prior to surgery, despite the lack of scientific evidence," said study author Adnan Z. Rizvi, MD, from the department of vascular and endovascular surgery at the Minneapolis Heart Institute® at Abbott Northwestern Hospital in Minneapolis. "However, studies have found increased bleeding with patients taking Plavix during open-heart surgery, so this surgery is an exception to our findings."
"In our practice, we previously stopped Plavix use prior to CEA. Yet, more recently, we have allowed some of our patients to continue with their anti-platelet therapy before undergoing CEA," explained Rizvi. "We decided to undertake this study to assess whether there were any higher bleeding complications associated with this decision." For the study, five board-certified vascular surgeons retrospectively analyzed 260 consecutive patients who underwent CEA at the Minneapolis Heart Institute® performed between June 2006 and April 2009. Fifty of these patients were taking clopidogrel during surgery, compared with nine patients who had their clopidogrel discontinued prior to surgery.
The technique selected for CEA was at the discretion of the operating surgeon, and included endarterectomy with a patch (Dacron, bovine pericardium or vein), angioplasty or eversion endarterectomy. The researchers found that the patients who were on clopidogrel had a longer operative time as compared with those who were on aspirin alone; however, operative blood loss was not statistically different. Interestingly, most of the bleeding complications that occurred in patients who were on clopidogrel occurred in patients who underwent endarterectomy with a Dacron patch angioplasty.
Based on their findings, Rizvi and colleagues concluded that carotid surgery can be safely performed on patients taking clopidogrel, but there is a higher risk of bleeding complications associated with using a Dacron patch. "However, if other techniques, such as eversion or bovine pericardium patch are used, then there is no different in bleeding complications with patients taking clopidogrel," Rizvi said. "With the exception of open-heart surgery, we suspect our findings can be translated for other surgeries, but a larger randomized study is warranted to support these conclusions," he concluded.