Although premature discontinuation of dual antiplatelet therapy (DAPT) is associated with an increased risk of ischemic complications, patients may present with an urgent need for surgery that would require interruption of DAPT. Antiplatelet bridge therapy using cangrelor, an intravenous P2Y12 inhibitor, has been studied as a potential option to ensure continuation of DAPT perioperatively. However, limited evidence exists supporting the off-label use of cangrelor bridge therapy to noncardiac procedures. We describe the case of a 67-year-old class 3 obese female on DAPT (aspirin and ticagrelor) for recent drug-eluting stent placement who required a bronchoscopy with biopsy for suspected lung cancer. Cangrelor bridge therapy was utilized both preoperatively and postoperatively without ischemic or bleeding complications, and the patient was subsequently able to begin radiation therapy after a confirmed diagnosis of lung cancer.
LevineGNBatesERBittlJA, et al.2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention, 2011 ACCF/AHA guideline for coronary artery bypass graft surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease, 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction, 2014 ACC/AHA guideline for the management of patients with non–ST-elevation acute coronary syndromes, and 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. J Am Coll Cardiol. 2016;68:1082–1115.
2.
ParkDWParkSWParkKH, et al.Frequency of and risk factors for stent thrombosis after drug-eluting stent implantation during long-term follow-up. Am J Cardiol. 2006;98(3):352–356.
3.
SharmaAHaiOGargA, et al.Duration of dual antiplatelet therapy following drug-eluting stent implantation: a systematic review and meta-analysis of randomized controlled trials. Curr Probl Cardiol. 2017;42(12):404–417.
4.
EisensteinELAnstromKJKongDF, et al.Clopidogrel use and long-term clinical outcomes after drug-eluting stent implantation. JAMA. 2007;297(2):159–168.
5.
HawnMTGrahamLARichmanJR, et al.The incidence and timing of noncardiac surgery after cardiac stent implantation. J Am Coll Surg. 2012;214(4):658–666.
6.
CapodannoDAngiolilloDJ. Management of antiplatelet therapy in patients with coronary artery disease requiring cardiac and noncardiac surgery. Circulation. 2013;128(25):2785–2798.
7.
Kengreal [package insert]. Parsippany, NJ: The Medicines Company; 2016.
8.
AngiolilloDJFirstenbergMSPriceMJ, et al.Bridging antiplatelet therapy with cangrelor in patients undergoing cardiac surgery. JAMA. 2012;307(3):265–274.
9.
ValgimigliMBuenoHByrneRA, et al.2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: the task force for dual antiplatelet therapy in coronary artery disease of the European society of cardiology (ESC) and of the European association for cardio-thoracic surgery (EACTS). Eur Heart J. 2018;39:213–260.
10.
GoldstrawPCrowleyJChanskyK, et al; International Association for the Study of Lung Cancer International Staging Committee; Participating Institutions. The IASLC lung cancer staging project: proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM classification of malignant tumors. J Thorac Oncol. 2007;2:706–714.
11.
CaylaGHulotJSO’ConnorSA, et al.Clinical, angiographic, and genetic factors associated with early coronary stent thrombosis. JAMA. 2011;306:1765–1774.
12.
van WerkumJWHeestermansAAZomerAC, et al.Predictors of coronary stent thrombosis: the Dutch Stent Thrombosis Registry. J Am Coll Cardiol. 2009;53:1399–1409.
13.
YounessHAKeddissiJBerimI, et al.Management of oral antiplatelet agents and anticoagulation therapy before bronchoscopy. J Thorac Dis. 2017;9(suppl 10):S1022–S1033.
14.
CarrIMKoegelenbergCFvon Groote-BidlingmaierF, et al.Blood loss during flexible bronchoscopy: a prospective observational study. Respiration. 2012;84:312–318.
15.
SwiatekDRGuthrieRElliottJ, et al.Antiplatelet exposure and bleeding events in patients undergoing EBUS-TBNA. Int J Respir Pulm Med. 2017;4(3):1–6.
16.
AlshawabkehLIPrasadALenkovskyF, et al.Outcomes of a preoperative “bridging” strategy with glycoprotein IIb/IIIa inhibitors to prevent perioperative stent thrombosis in patients with drug-eluting stents who undergo surgery necessitating interruption of thienopyridine administration. Euro Intervention. 2013;9:204–211.
17.
AngiolilloDJRolliniFStoreyRF, et al.International expert consensus on switching platelet P2Y12 receptor-inhibiting therapies. Circulation. 2017;136(20):1955–1975.
18.
RossiniRTarantiniGMusumeciG, et al.A multidisciplinary approach on the perioperative antithrombotic management of patients with coronary stents undergoing surgery: surgery after stenting 2. JACC Cardiovasc Interv. 2018;11(5):417–434.
19.
CahoonWDOswaltAKFrancisKE, et al.Cangrelor bridge therapy for gastroduodenal biopsy. J Pharm Pract. 2017;30(2):270–273.
