Perioperative clopidogrel is associated with increased bleeding and blood transfusion at the time of lower extremity bypass

Preoperative assessment of adults undergoing elective noncardiac surgery: Updated guidelines from the European Society of Anaesthesiology and Intensive Care

BACKGROUND

When considering whether a patient is fit for surgery, a comprehensive patient assessment represents the first step for an anaesthetist to evaluate the risks associated with the procedure and the patient's underlying diseases, and to optimise (whenever possible) the perioperative surgical journey. These guidelines from the European Society of Anaesthesiology and Intensive Care Medicine (ESAIC) update previous guidelines to provide new evidence on existing and emerging topics that consider the different aspects of the patient's surgical path.

DESIGN

A comprehensive literature review focused on organisation, clinical facets, optimisation and planning. The methodological quality of the studies included was evaluated using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology. A Delphi process agreed on the wording of recommendations, and clinical practice statements (CPS) supported by minimal evidence. A draft version of the guidelines was published on the ESAIC website for 4 weeks, and the link was distributed to all ESAIC members, both individual and national, encompassing most European national anaesthesia societies. Feedback was gathered and incorporated into the guidelines accordingly. Following the finalisation of the draft, the Guidelines Committee and ESAIC Board officially approved the guidelines.

RESULTS

In the first phase of the guidelines update, 17 668 titles were initially identified. After removing duplicates and restricting the search period from 1 January 2018 to 3 May 2023, the number of titles was reduced to 16 774, which were then screened, yielding 414 abstracts. Among these, 267 relevant abstracts were identified from which 204 appropriate titles were selected for a comprehensive GRADE analysis. Additionally, the study considered 4 reviews, 16 meta-analyses, 9 previously published guidelines, 58 prospective cohort studies and 83 retrospective studies. The guideline provides 55 evidence-based recommendations that were voted on by a Delphi process, reaching a solid consensus (>90% agreement).

DISCUSSION

This update of the previous guidelines has covered new organisational and clinical aspects of the preoperative anaesthesia assessment to provide a more objective evaluation of patients with a high risk of postoperative complications requiring intensive care. Telemedicine and more predictive preoperative scores and biomarkers should guide the anaesthetist in selecting the appropriate preoperative blood tests, x-rays, and so forth for each patient, allowing the anaesthetist to assess the risks and suggest the most appropriate anaesthetic plan.

CONCLUSION

Each patient should have a tailored assessment of their fitness to undergo procedures requiring the involvement of an anaesthetist. The anaesthetist's role is essential in this phase to obtain a broad vision of the patient's clinical conditions, to coordinate care and to help the patient reach an informed decision.

A Meta-Analysis to Derive Population-Based Quality Benchmarks of the Incidence of Surgical Site Infection after Lower Limb Revascularization Surgery

BACKGROUND

The reported incidence of surgical site infection (SSI) after lower limb revascularization surgery varies. We conducted a systematic review and meta-analysis of population-based studies reporting the incidence of SSI in adults who underwent these surgeries in high-income countries to derive SSI quality benchmarks.

METHODS

We searched MEDLINE, EMBASE, CENTRAL, and Evidence-Based Medicine Reviews (inception-to-April 28th, 2022) for population-based studies estimating the cumulative incidence of SSI among adults who underwent lower limb revascularization surgery for peripheral artery disease (PAD) in high-income countries. Two investigators independently screened abstracts and full-text articles, extracted data, and assessed risks of bias. We used random-effects models to pool data and GRADE to assess certainty.

RESULTS

Among 6,258 citations, we included 53 studies (n = 757,726 patients); 8 of which (n = 435,769 patients) reported nonoverlapping data that were meta-analyzed. The pooled cumulative incidence of any SSI was 6.0 in 100 patients [95% confidence interval (CI) = 4.3-8.0 in 100 patients; n = 8 studies; n = 435,769 patients; moderate certainty]. The cumulative incidence of Szilagyi grade I (cellulitis), grade II (subcutaneous tissue), and grade III (prosthetic graft) SSI was 6.5 in 100 patients (95% CI = 4.3-8.6 in 100 patients; n = 2 studies; n = 39,645 patients; low certainty), 2.1 in 100 patients (95% CI = 2.0-2.3 in 100 patients; n = 2 studies; low certainty), and 0.4 in 100 patients (95% CI = 0.4-0.4 in 100 patients; n = 1 study; n = 333,275 patients; low certainty), respectively. The pooled cumulative incidence of any early (in-hospital/≤30-days) and late (>30-days) SSI was 6.2 in 100 patients (95% CI = 4.4-8.0 in 100 patients; n = 7 studies; n = 431,273 patients; moderate certainty) and 3.7 in 100 patients (95% CI = 2.2-5.2 in 100 patients; n = 2 studies; n = 10,565 patients; low certainty), respectively.

CONCLUSIONS

This systematic review derived population-based benchmarks of the incidence of any SSI; Szilagyi I, II, and III SSI; and early and late SSI after lower limb revascularization surgery. These may be used by practicing surgeons and healthcare leaders/administrators to guide quality improvement efforts in the United States and perhaps other countries.

Population Pharmacokinetic/Pharmacodynamic Models for P2Y12 Inhibitors: A Systematic Review and Clinical Appraisal Using Exposure Simulation

BACKGROUND AND OBJECTIVE

Recent research indicates a correlation between plasma concentration of P2Y12 inhibitors and clinical events, particularly bleeding, which significantly impeded their clinical therapeutic performance. It is therefore vital to delve into the factors that might affect the plasma concentration. The study aims to summarize population pharmacokinetics/pharmacodynamics (PopPKPD) models for commonly prescribed P2Y12 inhibitors (clopidogrel, prasugrel, and ticagrelor) and assess bleeding risk in specific individual groups.

METHODS

The PopPKPD models of P2Y12 inhibitors were collected and summarized based on predetermined inclusion and exclusion criteria. The collected models were replicated in simulations, which were used to assess factors affecting plasma concentrations of P2Y12 inhibitors. Simulation results for special populations were compared to therapeutic window based on reported exposure-effect relationships (PK/PD-related bleeding and thrombotic clinical outcomes) to predict bleeding risk in special populations with different dosing regimens and cumulative covariates.

RESULT

Finally, 12 studies were included for PK simulation, 7 of which that also included PD data were subjected to further analysis, with the majority being based on Phase I or II trials. Simulations showed that several covariates such as female gender, weight, elderly can significantly impact on exposure, with special populations reaching up to 179% of the general population. However, after dose adjustment, blood concentrations for special populations can reach approximately ±20% of general population exposure. Therefore, lowering the maintenance dose of ticagrelor from 90 to 60 mg bid was first recommended to reduce bleeding risk without significantly increasing ischemic risk, particularly in elderly, small-weight Asian females.

CONCLUSION

Lowering the maintenance dose of ticagrelor from 90 to 60 mg bid effectively reduces bleeding risk without increasing thrombotic infarction risk in elderly, small-weight Asian females.

Contemporary outcomes of traumatic popliteal artery injury repair from the popliteal scoring assessment for vascular extremity injury in trauma study

OBJECTIVE

Traumatic popliteal artery injuries are associated with the greatest risk of limb loss of all peripheral vascular injuries, with amputation rates of 10% to 15%. The purpose of the present study was to examine the outcomes of patients who had undergone operative repair for traumatic popliteal arterial injuries and identify the factors independently associated with limb loss.

METHODS

A multi-institutional retrospective review of all patients with traumatic popliteal artery injuries from 2007 to 2018 was performed. All the patients who had undergone operative repair of popliteal arterial injuries were included in the present analysis. The patients who had required a major lower extremity amputation (transtibial or transfemoral) were compared with those with successful limb salvage at the last follow-up. The significant predictors (P < .05) for amputation on univariate analysis were included in a multivariable analysis.

RESULTS

A total of 302 patients from 11 institutions were included in the present analysis. The median age was 32 years (interquartile range, 21-40 years), and 79% were men. The median follow-up was 72 days (interquartile range, 20-366 days). The overall major amputation rate was 13%. Primary repair had been performed in 17% of patients, patch repair in 2%, and interposition or bypass in 81%. One patient had undergone endovascular repair with stenting. The overall 1-year primary patency was 89%. Of the patients who had lost primary patency, 46% ultimately required major amputation. Early loss (within 30 days postoperatively) of primary patency was five times more frequent for the patients who had subsequently required amputation. On multivariate regression, the significant perioperative factors independently associated with major amputation included the initial POPSAVEIT (popliteal scoring assessment for vascular extremity injury in trauma) score, loss of primary patency, absence of detectable immediate postoperative pedal Doppler signals, and lack of postoperative antiplatelet therapy. Concomitant popliteal vein injury, popliteal injury location (P1, P2, P3), injury severity score, and tibial vs popliteal distal bypass target were not independently associated with amputation.

CONCLUSIONS

Traumatic popliteal artery injuries are associated with a significant rate of major amputation. The preoperative POPSAVEIT score remained independently associated with amputation after including the perioperative factors. The lack of postoperative pedal Doppler signals and loss of primary patency were highly associated with major amputation. The use of postoperative antiplatelet therapy was inversely associated with amputation, perhaps indicating a protective effect.

Impact of Procedural Bleeding in Peripheral Artery Disease

Background:

The relationship between invasive vascular procedures and bleeding in patients with peripheral artery disease has not been well described in the literature. This post hoc analysis from the EUCLID trial (Examining Use of Ticagrelor in Peripheral Artery Disease) aimed to describe the incidence of major and minor postprocedural bleeding and characterize the timing and severity of bleeding events relative to the procedure.

Methods:

EUCLID was a multicenter, randomized controlled trial of 13 885 patients with symptomatic peripheral artery disease that tested the efficacy and safety of ticagrelor compared with clopidogrel for the prevention of major adverse cardiovascular events. A total of 2661 patients underwent 3062 coronary revascularization, peripheral revascularization, and amputation during the study. The primary safety end point was Thrombolysis in Myocardial Infarction major or minor bleeding. All bleeding events were formally adjudicated by a clinical end point classification group.

Results:

Major bleeding events most often occurred ≤7 days following the procedure. The incidence of Thrombolysis in Myocardial Infarction major or minor bleeding ≤7 days following peripheral revascularization (3.3%; 95% CI, 2.5%–4.1%) was similar to rates after coronary revascularization (4.0%; 95% CI, 2.6%–5.4%) and lower extremity amputation (2.3%; 95% CI, 0.8%–3.8%). The severity of bleeding events (as graded by drop in hemoglobin, need for transfusion, bleeding in a critical location, and fatal bleeding) was also similar following peripheral, coronary revascularization, and lower extremity amputation.

Conclusions:

The incidence of Thrombolysis in Myocardial Infarction major/minor bleeding following peripheral revascularization is comparable to rates after coronary revascularization and lower extremity amputation, and the majority of bleeding events occur within 7 days following the procedure. The severity of periprocedural bleeding is also similar after procedures, with the most frequently adjudicated reason being a drop in hemoglobin ≥2 g/dL. Future studies should be performed to enhance our understanding of bleeding risk related to revascularization and amputation procedures in peripheral artery disease patients.

Utilization of Vasculoprotective Therapy for Peripheral Artery Disease: A Systematic Review and Meta-analysis

INTRODUCTION

Practice guidelines recommend that patients with peripheral artery disease receive antiplatelets, statins, and angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). We sought to quantify the rates of prescribing these therapies in patients with peripheral artery disease in the literature.

METHODS

We performed a systematic review and meta-analysis of treatment prescribing rates in observational studies containing peripheral artery disease patients published on or after the year 2000. We also assessed whether prescribing rates are increasing over time.

RESULTS

A total of 86 studies were available for analysis. The aggregate sample size across all studies was 332,555. The pooled estimates for utilization of antiplatelets, statins, and ACE inhibitors or ARBs were 75% (95% confidence interval [CI], 71%-79%), 56% (95% CI, 52%-60%), and 53% (95% CI, 49%-58%), respectively. Statin use was directly related to publication year (+2.0% per year, P < .001), but this was not the case for antiplatelets (P = .68) or ACE inhibitors or ARBs (P = .066).

CONCLUSIONS

Although some improvement in statin prescribing has occurred in recent years, major practice gaps exist in the treatment of peripheral artery disease. Effective measures to close these gaps should be implemented.