70+ yo male with previous meningioma. Now for cranioplasty for cosmetic purposes.

Background:

• Meningioma – excised, followed by craniectomy for infected bone flap.
• Metastatic bowel cancer (liver met)
• AF
• IHD
  • NSTEMI Feb ’21, precipitated by reduced exercise tolerance and angina.
  • On apixaban and aspirin (for AF and PCI)

Discussion

• 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.

Plan

• Proceed to OT.
• Continue aspirin.
• Withhold anticoagulant. No bridging therapy.