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Rossini R, Masiero G, Fruttero C, Passamonti E, Calvaruso E, Cecconi M, Carlucci C, Mojoli M, Guido P, Talanas G, Pierini S, Canova P, De Cesare N, Luceri S, Barzaghi N, Melloni G, Baralis G, Locatelli A, Musumeci G, Angiolillo DJ. Antiplatelet Therapy with Cangrelor in Patients Undergoing Surgery after Coronary Stent Implantation: A Real-World Bridging Protocol Experience. TH Open 2020; 4:e437-e445. [PMID: 33376943 PMCID: PMC7758156 DOI: 10.1055/s-0040-1721504] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 11/02/2020] [Indexed: 01/04/2023] Open
Abstract
Objective
The aim of the study is to describe the real-world use of the P2Y
12
inhibitor cangrelor as a bridging strategy in patients at high thrombotic risk after percutaneous coronary intervention (PCI) and referred to surgery requiring perioperative withdrawal of dual antiplatelet therapy (DAPT).
Materials and Methods
We collected data from nine Italian centers on patients with previous PCI who were still on DAPT and undergoing nondeferrable surgery requiring DAPT discontinuation. A perioperative standardized bridging protocol with cangrelor was used.
Results
Between December 2017 and April 2019, 24 patients (mean age 72 years; male 79%) were enrolled. All patients were at high thrombotic risk after PCI and required nondeferrable intermediate to high bleeding risk surgery requiring DAPT discontinuation (4.6 ± 1.7 days). Cangrelor infusion was started at a bridging dose (0.75 µg/kg/min) 3 days before planned surgery and was discontinued 6.6 ± 1.5 hours prior to surgical incision. In 55% of patients, cangrelor was resumed at 9 ± 6 hours following surgery for a mean of 39 ± 38 hours. One cardiac death was reported after 3 hours of cangrelor discontinuation prior to surgery. No ischemic outcomes occurred after surgery and up to 30-days follow-up. The mean hemoglobin drop was <2 g/dL; nine patients received blood transfusions consistent with the type of surgery, but no life-threatening or fatal bleeding occurred.
Conclusion
Perioperative bridging therapy with cangrelor is a feasible approach for stented patients at high thrombotic risk and referred to surgery requiring DAPT discontinuation. Larger studies are warranted to support the safety of this strategy.
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Affiliation(s)
| | | | | | - Enrico Passamonti
- Ospedale di Cremona, Struttura Complessa di Cardiologia, Cremona, Italy
| | - Elba Calvaruso
- Ospedale di Cremona, Struttura Complessa di Cardiologia, Cremona, Italy
| | | | | | - Marco Mojoli
- Ospedale Santa Maria degli Angeli, Pordenone, Pordenone, Italy
| | - Parodi Guido
- Azienda Ospedaliera Universitaria di Sassari, Struttura Complessa di Cardiologia Clinica ed Interventistica, Sassari, Italy
| | - Giuseppe Talanas
- Azienda Ospedaliera Universitaria di Sassari, Struttura Complessa di Cardiologia Clinica ed Interventistica, Sassari, Italy
| | - Simona Pierini
- P.O. BASSINI-ASST Nord Milano, U.O.C. Cardiologia, Milano, Italy
| | - Paolo Canova
- ASST Papa Giovanni XXIII, Unità di Cardiologia 2, Bergamo, Italy
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Rossini R, Masiero G, Fruttero C, Passamonti E, Calvaruso E, Cecconi M, Carlucci C, Barzaghi N, Locatelli A, Mojoli M, Parodi G, Talanas G, Pierini S, Angiolillo D, Musumeci G. P2815Antiplatelet therapy with cangrelor in patients undergoing surgery after coronary stent implantation: a real-world bridging protocol experience. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.1127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Perioperative management of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) in patients deemed at high thrombotic risk undergoing non-deferrable surgery remains poorly defined. Cangrelor represents a potential treatment option as a “bridge” from discontinuation of oral P2Y12 receptor antagonists to surgical procedures, but data in this setting are still scant.
Purpose
We sought to describe a real-world experience of a bridging protocol using cangrelor for patients referred to relevant bleeding risk surgery requiring withdrawal of DAPT.
Methods
We collected data from 7 Italian centers on patients with previous PCI, still on DAPT, undergoing non-deferrable surgery which required discontinuation of one or both antiplatelet agents. A standardized bridging protocol using cangrelor infusion before and eventually after surgery was applied (Figure 1).
Results
Between December 2017 and January 2019, a total of 18 patients (mean age 70±10 years; male 85%) were enrolled. In the majority (89%) of patients, the index PCI was performed due to acute coronary syndrome (ACS) and 2±1.7 stents per patient were implanted. All patients required non-deferrable, intermediate-high bleeding risk surgery as pulmonary lobectomy, colectomy, endoscopic bladder surgery, paranasal sinus surgery, coronary artery by-pass surgery and valvular repair, hip replacement, endoscopy sphincterotomy. High thrombotic risk categories included PCI time <1 month, SCA time <3 months, stent failure occurrence, previous Absorb BVS implantation. Due to the surgical bleeding risk, discontinuation of P2Y12 inhibitor was required 5 days before surgery (ticagrelor, n=13; prasugrel=1; clopidogrel, n=5). All patients but 1 maintained aspirin through the perioperative phase. Cangrelor infusion was started at a bridging dose (0.75 mcg/kg/min) 3 days before planned surgery and was discontinued 6.9±1.5 hours before. After surgery, drainages were left in all patients but 3. In 56% of patients, cangrelor was resumed within 24 hours from surgery (mean time 9±7 hours) for a mean of 36±38 hours. Drainages were removed after discontinuation of cangrelor, in order to reduce bleeding complications. Within 2 hours from post-operative cangrelor discontinuation, a 300 mg clopidogrel loading dose was administered. No major ischemic adverse outcomes occurred during hospital stay and up to 30 days follow-up. The mean Hb drop was 2±1.8 g/dl, 7 patients received blood transfusions consistent with the type of surgeries and no life-threatening or fatal bleeding occurred.
Figure 1. Standardized bridging protocol.
Conclusions
Peri-operative bridge therapy with cangrelor is a feasible approach for stented patients at high thrombotic risk referred to non-deferrable surgery requiring DAPT discontinuation. Larger studies are warranted to support the safety of this strategy.
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Affiliation(s)
- R Rossini
- Santa Croce E Carle Hospital, Cuneo, Italy
| | - G Masiero
- Santa Croce E Carle Hospital, Cuneo, Italy
| | - C Fruttero
- Santa Croce E Carle Hospital, Cuneo, Italy
| | | | | | - M Cecconi
- Hospital of Civitanova Marche, Civitanova Marche, Italy
| | - C Carlucci
- Hospital of Civitanova Marche, Civitanova Marche, Italy
| | - N Barzaghi
- Santa Croce E Carle Hospital, Cuneo, Italy
| | | | - M Mojoli
- Santa Maria degli Angeli Hospital, Pordenone, Italy
| | - G Parodi
- University of Sassari, Sassari, Italy
| | - G Talanas
- University of Sassari, Sassari, Italy
| | - S Pierini
- P.O. BASSINI - ASST Nord Milano, Milano, Italy
| | - D Angiolillo
- College of Medicine-Jacksonville, Jacksonville, United States of America
| | - G Musumeci
- Santa Croce E Carle Hospital, Cuneo, Italy
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Merlano MC, Merlotti AM, Licitra L, Denaro N, Fea E, Galizia D, Di Maio M, Fruttero C, Curcio P, Vecchio S, Russi EG, Corvò R. Activation of immune responses in patients with relapsed-metastatic head and neck cancer (CONFRONT phase I-II trial): Multimodality immunotherapy with avelumab, short-course radiotherapy, and cyclophosphamide. Clin Transl Radiat Oncol 2018; 12:47-52. [PMID: 30186977 PMCID: PMC6107891 DOI: 10.1016/j.ctro.2018.08.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/04/2018] [Accepted: 08/09/2018] [Indexed: 01/06/2023] Open
Abstract
Treatment of relapsed/metastatic head and neck cancer is unclear. Cyclophosphamide, avelumab, and radiotherapy may be effective for R/M-HNC. Combined treatment may improve avelumab activity without increasing its toxicity. Ongoing trials will clarify the potential of immunotherapy in RM-HNC patients.
Introduction and background Second-line treatment of platinum-resistant relapsed/metastatic (R/M) head and neck cancer (HNC) is a currently unmet clinical need. Clinical trials showed improvement in overall survival and quality of life of R/M-HNC patients treated with anti-PD-1 regardless of the number of prior chemotherapy lines; however, the percentage of long-term survivors remains limited. This study aims to test the hypothesis that attacking the tumor microenvironment at multiple levels can increase immunogenicity of R/M-HNC without worsening the safety profile of immune checkpoint inhibitors. Methods/design In this open label, multi-center, single-arm, Phase Ib/II, R/M-HNC patients pretreated with at least one line of therapy containing platinum, fluorouracil, and cetuximab will receive a daily metronomic dose of 50 mg cyclophosphamide without a drug-free break, 10 mg/kg avelumab on day 1 and every other week until progression, and a single fraction of 8 Gy radiotherapy on day 8. Discussion The treatment protocol aims to reverse immune evasion of the tumor through a radiotherapy-induced self-vaccination effect, suppression of CD4+ CD25+ FoxP3+ regulatory T-cell function by metronomic cyclophosphamide, and effector T-cell reactivation owing to the inhibition of the PD-1–PD-L1 axis by avelumab. The immunologic interplay induced by the proposed combined treatment may theoretically improve the activity of avelumab without increasing its toxicity profile. Finally, an ancillary translational study will be extended to all the patients’ population. Trial registration EudraCT n. 2017-000353-39.
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Affiliation(s)
| | - Anna M. Merlotti
- Radiation Oncology A.O. S.Croce e Carle, Cuneo, Italy
- Corresponding author at: Radiation Oncology, A.O. S.Croce e Carle, via M.Coppino 26, 12100 Cuneo, CN, Italy.
| | - Lisa Licitra
- Medical Oncology Fondazione IRCCS Istituto Nazionale dei Tumori and University of Milan, Milan, Italy
| | | | - Elena Fea
- Medical Oncology A.O. S.Croce e Carle, Cuneo, Italy
| | - Danilo Galizia
- Investigative and Clinical Oncology, Candiolo Cancer Institute – FPO, IRCCS, Italy
| | - Massimo Di Maio
- Medical Oncology Mauriziano Hospital, University of Torino, Italy
| | | | | | - Stefania Vecchio
- Medical Oncology, IRCCS Sn Martino, IST National Cancer Research Institute and University, Genova, Italy
| | | | - Renzo Corvò
- Radiation Oncology, IRCCS S. Martino, IST National Cancer Research Institute and University, Genova, Italy
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Passalacqua S, Staffolani E, Brescia P, Loschiavo C, Mancini E, Monaci G, Russo GE, Ramunni A, Granger Vallee A, Chenine L, Leray-Moragues H, Gontier-Picard A, Rodriguez A, Chalabi L, Canaud B, Lantz B, Kapke A, Pearson J, Vanholder R, Tomo T, Robinson B, Port F, Daugirdas J, Ramirez S, Akonur A, Agar BU, Culleton BF, Gellens ME, Leypoldt JK, Agar BU, Troidle L, Finkelstein FO, Kohn OF, Akonur A, Leypoldt JK, Basile C, Libutti P, Di Turo AL, Casucci F, Losurdo N, Teutonico A, Vernaglione L, Lomonte C, Basile C, Libutti P, Vernaglione L, Casucci F, Losurdo N, Teutonico A, Lomonte C, Umimoto K, Nata Y, Shimamoto Y, Miyata M, Krisp C, Gmerek A, Wagner J, Wolters D, Pedrini LA, Kopec J, Sulowicz W, Falkenhagen D, Thijssen S, Brandl M, Hartmann J, Strobl K, Wallner M, Mahieu E, Verhamme P, Op De Beeck K, Kuypers D, Claes K, Vitale C, Bagnis C, Berutti S, Soragna G, Gabella P, Fruttero C, Marangella M, Khadzhynov D, Baumann C, Lieker I, Slowinski T, Neumayer HH, Peters H, Bibiano L, Freddi P, Ricciatti A, Sagripanti S, Manarini G, Frasca GM, Hwang KS, Park JS, Lee CH, Kang CM, Kim GH, Urabe S, Kokubo K, Tsukao H, Shimbo T, Hirose M, Kobayashi H, Itoh Y, Kikuchi K, Murakami K, Tsuruta Y, Niwa T, Masakane I, Esashi S, Igarashi H, Djogan M, Boltina I, Dudar I, Pastori G, Favaro E, Ferraro A, Marcon R, Guizzo M, Lazzarin R, Conte F, Nichelatti M, Limido A, Zhu F, Liu L, Kaysen GA, Abbas SR, Kotanko P, Levin NW, Debska-Slizien A, Malgorzewicz S, Dudziak M, Rutkowski B, Svojanovsky J, Dob ak P, Nedbalkova M, Reichertova A, Soucek M, Kirmizis D, Kougioumtzidou O, Vakianis P, Papagianni A, Mancini E, Sestigiani E, Gissara Z, Palladino G, Santoro A, Schneditz D, Stockinger J, Ribitsch W, Branco P, Figueiredo S, Santana S, Rocha C, Carvalho L, Borges S, Marques D, Barata D, Tomo T, Matsuyama M, Matsuyama K, Matsuyama I, Minakuchi J, Schiffl H, Fischer R, Lang S, de los Santos CA, Antonello IC, Poli-de-Figueiredo CE, d'Avila D, Abbas SR, Zhu F, Liu L, Rosales L, Ulloa D, Carter M, Kotanko P, Levin NW, Murakami K, Kokubo K, Tsukao H, Shimbo T, Hirose M, Kobayashi H, Kokubo K, Umehara S, Tsukao H, Shimbo T, Hirose M, Sakai K, Kobayashi H, Krieter DH, Seidel S, Merget K, Lemke HD, Morgenroth A, Wanner C, Onogi T, Nishida Y, Ueno J, Taoka M, Sato T, Sakurai K, Saito T, Yamauchi F, Asahi D, Hosoya H, Maruyama N, Suzuki A, Kokubo K, Alain R, Christian D, Romano JM, Printz J, Philippe B, Micha T, Hadjiyannakos D, Pani I, Sonikian M, Karatzas I, Vlassopoulos D, Kanaki A, Caprioli R, Lippi A, Donadio C, Malliekal S, Kubey W, Bernardo AA, Canaud B, Katzarski K, Galach M, Waniewski J, Sambale S, Reising A, Donnerstag F, Hafer C, Schmidt B, Kielstein JT, Ervo R, Angeletti S, Turrini Dertenois L, Cavatorta F, Gondouin B, Bevins A, Cockwell P, Hutchison CA, Doria M, Genovesi S, Biagi F, Grandi F, Frontini A, Stella A, Santoro A, Cases A, Fort J, Maduell F, Comas J, Arcos E, Deulofeu R, Rroji (Molla) M, Seferi S, Barbullushi M, Spahia N, Likaj E, Thereska N, Morena M, Rodriguez A, Jaussent I, Chenine L, Bargnoux AS, Dupuy AM, Leray-Moragues H, Cristol JP, Canaud B, Gondouin B, Hutchison CA, Hammer F, Scherberich JE, Pizzarelli F, Ferro G, Amidone M, Dattolo P, Gauly A, Golla P, Hafer C, Clajus C, Beutel G, Haller H, Schmidt BMW, Kielstein J, Nakazawa R, Shimizu Y, Uemura Y, Kashiwabara H, Watanabe D, Kato T, Fuse M, Azuma N, Nakanishi N, Kabayama S, Alquist Hegbrant M, Bosch JP, Righetti M, Ferrario G, Serbelloni P, Milani S, Lisi L, Tommasi A, Leypoldt JK, Agar BU, Akonur A, Gellens ME, Culleton BF, Santoro A, Mancini E, Mambelli E, Bolasco PG, Scotto P, Savoldi S, Serra A, Limido A, Corazza L, Sakurai K, Saito T, Yamauchi F, Asahi D, Hosoya H, Tomisawa N, Jinbo Y, Umimoto K, Shimamoto Y, Kobayashi Y, Miyata M, Tsukao H, Kokubo K, Kawakubo Y, Sakurasawa T, Shimbo T, Hirose M, Kobayashi H. Extracorporeal dialysis: techniques and adequacy. Clin Kidney J 2011. [DOI: 10.1093/ndtplus/4.s2.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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