Two case of preoperative bridging therapy for patients undergoing non-cardiac surgery after coronary stent implantation

It has been reported that up to 12% of patients underwent non-cardiac surgery or invasive procedures within the first year after the coronary stent implantation. Premature discontinuation of antiplatelet therapy is associated with a significant increase in mortality and major adverse cardiac events, in particular, stent thrombosis. Thus, postponement of elective surgery is advocated during the first year after the coronary stent implantation. However, if non-deferrable surgery is required within this 12-month period, recommendations are less clear. For such patients, preoperative administration of a short-acting intravenous agent has been proposed to reduce the risk of perioperative stent thrombosis.  Tirofiban is a low-molecular weight, competitive and short-acting GPIIb/IIIa receptor inhibitor. After stopping administration of tirofiban, platelet aggregation recovers to 50% of the baseline value within 4 h. This letter introduces two cases underwent non-cardiac surgery with the bridging therapy of tirofiban when oral antiplatelet agents were temporally withdrawn. The first patient is an 81-year-old female, who presented with non-ST-elevation myocardial infraction (NSTEMI). The dual antiplatelet therapy of aspirin and ticagrelor was administered immediately. Coronary angiography revealed a long and heavily calcified lesion with severe stenosis involving the mid-left anterior descending artery (LAD), (Figure 1). A drug-eluting stent (DES, 2.75 mm × 36 mm, Partner stent, Lepu medical, China) was successfully inserted in the LAD. During hospitalization, the patient accidentally fell down, causing right distal femoral fracture. Her hemoglobin level dropped from 105 g/L to 75 g/L considering the hematoma of the thigh. Ticagrelor was withdrawn because of the aggravated swelling of the right limb. Aspirin