70+ yo male with previous meningioma. Now for cranioplasty for cosmetic purposes.
- Meningioma – excised, followed by craniectomy for infected bone flap.
- Metastatic bowel cancer (liver met)
- NSTEMI Feb ’21, precipitated by reduced exercise tolerance and angina.
- On apixaban and aspirin (for AF and PCI)
- Should surgery proceed?
- Patient feels this will significantly add to his QoL
- Plan pending for his metastatic bowel cancer, potential candidate for a partial liver resection in the future.
- Oncologist suggests 2yr survival from the bowel cancer is reasonable (supporting decision for cranioplasty) and that this surgery won’t negatively affect his liver metastasis prognosis.
- Craniectomy can be therapeutic in the setting of previous decompressive craniectomy, speeding neurocognitive recovery. Not relevant to this patient.
- How to manage antiplatelet and anticoagulant agents, and timing since PCI for non-urgent surgery
- NSx happy to perform procedure on aspirin
- Discussed at anaesthetics-cardiology MDT – waiting until 12mth post PCI will not reduce this patient’s risk of MACE, especially if aspirin is able to continue perioperatively
- Bridging not indicated. CHADS2 score = moderate risk. Evidence continues to support no bridging in this patient group due to increased bleeding risk without prevention of thromboembolic events.
- Proceed to OT.
- Continue aspirin.
- Withhold anticoagulant. No bridging therapy.