Early Aspirin For Prevention Of Thrombotic Saphenous Vein Graft Occlusion: What Is The Best Practice?
Philemon Gukop1, Rajdeep Bilkhu1, Georgios T. Kanapanagiotidis2, Venkatachalam Chandrasekaran1, Mazin Sarsam1, Aziz Momin1.
1St George's University Hospital NHS foundation Trust London United Kingdom, London, United Kingdom, 2Cardiothoracic Surgery Department, AHEPA University Hospital, Thessaloniki, Greece, Thessaloniki, Greece.
Early thrombotic saphenous vein graft (SVG) occlusion is a significant source of morbidity and mortality. Class 1a evidence confirm that early aspirin administered within 24hours following CABG is preventive of SVG occlusion and has prognostic value. AHA/ACC/EACTS guidelines recommend administration of aspirin within 6 hours following CABG or when bleeding settles for prevention of thrombotic SVG occlusion. The efficacy of aspirin is higher with earlier administration. we review current evidence to identify grey areas for improvement of current practice.
METHODS: Systematic review of best evidence for the use of early aspirin in prevention of early thrombotic vein graft occlusion following CABG. pubmed and ovid Search (1950-2015) with Themes ( early vein graft occlusion, early aspirin, postoperative bleeding, thrombotic graft occlusion, vein graft failure.) the best evidence were analysed and conclusion made.
RESULTS: class 1a evidence established the value of early aspirin for prevention of thrombotic SVG occlusion, No evidence associating early aspirin with postoperative bleeding. No guidance for patients on aspirin until surgery. Resistance to aspirin and clopidogrel in the general population is upto 40% and 15% respectively. Some guidelines recommend dual anti-platelets for 1 year post NSTEMI. Newer more potent anti-platelets have not been considered. The sooner aspirin is administered the higher its potency, highest potency was noted when administered at 1 hour and no effect after 24 hours. The highest value of early aspirin was for grafts to smaller arteries and poor targets.
CONCLUSIONS: Early aspirin is potent for prevention of thrombotic SVG occlusion . Patients already on aspirin until surgery may not require loading dose. Resistance to aspirin and clopidogrel in the general population is significant. No evidence associating Early aspirin with postoperative bleeding. There is need to pre-test the efficacy of anti-platelets with multiplex prior to administration in individual cases. Individualized, multiplex guided best anti-platelet therapy for prevention of SVG thrombotic occlusion should be the standard of care. Anti-platelets could be administered as soon as possible within 1-6 hours in the postoperative period. Clinical judgement of the operating team is key guidance to optimal administration time for best outcome.There is need for revision of the current guidelines.
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