"Bail-Out" Bivalirudin Use in Patients With Thrombotic Complications
"Bail-Out" Bivalirudin Use in Patients With Thrombotic Complications
Percutaneous coronary intervention (PCI) is routinely performed in patients with non-ST elevation acute coronary syndromes after pretreatment with clopidogrel and periprocedural administration of unfractionated heparin on a weight-adjusted basis. Although activated clotting time (ACT) monitoring is encouraged to verify the adequacy of anticoagulation during the procedures, this is not a common practice in many laboratories. The Authors describe 4 cases of patients with bifurcation lesions involving the left anterior descending coronary artery, who developed periprocedural thrombosis with acute transmural ischemia. All patients had inadequate ACT measurements, despite conventional heparin dosage and ongoing clopidogrel treatment. In order to achieve complete anticoagulation, patients were switched to bivalirudin, which determined a prompt effect on measured ACT. This therapeutic regimen, coupled with further intervention, allowed resolution of the thrombotic complication without bleeding. This report suggests the feasibility of a strategy of bivalirudin use in patients who have some degree of heparin "resistance" in the setting of complicated PCI.
Percutaneous coronary intervention (PCI) is routinely performed in interventional catheterization laboratories to revascularize patients with either unstable or stable coronary syndromes. In order to reduce the risk of thrombotic complications, periprocedural treatment includes aspirin, unfractionated heparin on a weight-adjusted basis, and clopidogrel, especially effective for patients undergoing stent implantation. Despite these measures, thrombotic complications during PCI do occur, particularly in patients with preexisting intracoronary thrombus during complex procedures or as a consequence of coronary dissection. These complications are most commonly seen in acute coronary syndromes, as a manifestation of systemic activation of the coagulation system, while they are less common in patients who have been successfully stabilized with medical therapy. We report 4 cases of patients with recent-onset angina who underwent PCI on a bifurcation lesion in the anterior territory after pretreatment with aspirin and clopidogrel and who developed intracoronary thrombosis refractory to conventional treatment. These patients were successfully managed with the use of "bail-out" bivalirudin.
Percutaneous coronary intervention (PCI) is routinely performed in patients with non-ST elevation acute coronary syndromes after pretreatment with clopidogrel and periprocedural administration of unfractionated heparin on a weight-adjusted basis. Although activated clotting time (ACT) monitoring is encouraged to verify the adequacy of anticoagulation during the procedures, this is not a common practice in many laboratories. The Authors describe 4 cases of patients with bifurcation lesions involving the left anterior descending coronary artery, who developed periprocedural thrombosis with acute transmural ischemia. All patients had inadequate ACT measurements, despite conventional heparin dosage and ongoing clopidogrel treatment. In order to achieve complete anticoagulation, patients were switched to bivalirudin, which determined a prompt effect on measured ACT. This therapeutic regimen, coupled with further intervention, allowed resolution of the thrombotic complication without bleeding. This report suggests the feasibility of a strategy of bivalirudin use in patients who have some degree of heparin "resistance" in the setting of complicated PCI.
Percutaneous coronary intervention (PCI) is routinely performed in interventional catheterization laboratories to revascularize patients with either unstable or stable coronary syndromes. In order to reduce the risk of thrombotic complications, periprocedural treatment includes aspirin, unfractionated heparin on a weight-adjusted basis, and clopidogrel, especially effective for patients undergoing stent implantation. Despite these measures, thrombotic complications during PCI do occur, particularly in patients with preexisting intracoronary thrombus during complex procedures or as a consequence of coronary dissection. These complications are most commonly seen in acute coronary syndromes, as a manifestation of systemic activation of the coagulation system, while they are less common in patients who have been successfully stabilized with medical therapy. We report 4 cases of patients with recent-onset angina who underwent PCI on a bifurcation lesion in the anterior territory after pretreatment with aspirin and clopidogrel and who developed intracoronary thrombosis refractory to conventional treatment. These patients were successfully managed with the use of "bail-out" bivalirudin.
