PIG Meeting: 8th April 2021

58-year-old lady for repair of a thoraco-abdominal aortic aneurysm

Background

• Significant vascular disease; 4.8cm aortic aneurysm, renal artery stenosis of single functioning kidney
• Mesenteric ischaemia requiring inferior mesenteric artery stent in 2020. On life-long Dual antiplatelet therapy (DAPT)
• Ex-smoker, 40+pack year history
• Active, no limiting symptoms. Works in aged care.

Issues

• Surgeon requesting CSF drain insertion for spinal cord protection but would like patient to remain on DAPT. (See attached paper on CSF Drain for SC Protection)
• Phone call to surgeon explaining that DAPT would need to be ceased in order to facilitate a neuraxial procedure
• Significant surgical concerns for IMA stent patency if DAPT were to be ceased

Discussion

• Discussed with haematologist, platelet transfusion would not be a solution
• Multiple possible options presented including brief cessation of clopidogrel and insertion of drain day before. Issue of what to do when epidural catheter in and for removal discussed.
• Tirofiban discussed due to its reversibility – limited experience  
• Can the procedure be postponed allowing a longer time period between insertion of the IMA stent and cessation of DAPT?
• Consensus that insertion of the CSF drain prophylactically while on DAPT would not be accepted safe practice

Plan

• Issues discussed with surgeon. Agrees for clopidogrel to be ceased pre-operatively to facilitate CSF drain.