Abciximab and bleeding during coronary surgery: results from the EPILOG and EPISTENT trials. Improve Long-term Outcome with abciximab GP IIb/IIIa blockade. Evaluation of Platelet IIb/IIIa Inhibition in STENTing.

BACKGROUND: Abciximab during percutaneous coronary revascularization reduces ischemic complications, but concern exists regarding increased bleeding risk should emergency coronary surgical procedures be required. METHODS: Outcomes were assessed among 85 patients who required coronary artery bypass grafting operations after coronary intervention in two randomized placebo-controlled trials of abciximab. Comparisons were made between patients in the pooled placebo and abciximab groups. RESULTS: The incidence of coronary surgical procedures was 2.17% and 1.28% among patients randomized to placebo and abciximab, respectively (p = 0.021). Platelet transfusions were administered to 32% and 52% of patients in the placebo and abciximab groups, respectively (p = 0.059). Rates of major blood loss were 79% and 88% in the placebo and abciximab groups, respectively (p = 0.27); transfusions of packed red blood cells or whole blood were administered in 74% and 80% of patients, respectively (p = 0.53). Surgical reexploration for bleeding was required in 3% and 12% of patients, respectively. Death and myocardial infarction tended to occur less frequently among patients who had received abciximab. CONCLUSIONS: Urgent coronary artery bypass grafting operations can be performed without an incremental increase in major hemorrhagic risk among patients on abciximab therapy.

Coronary artery bypass graft in abciximab-treated patients.

In an assessment of available literature regarding appropriate treatment algorithms for patients who fail cardiac interventions and require coronary bypass grafting with abciximab "on board," few surgeons reported significant variation in bleeding or other issues. There are many problems with postmarketing data collection, and such data would lack rigor and randomization. Prospective collection of data would be extremely difficult. Few patients go to surgery nowadays, and it is generally believed that because of the wealth of data supporting glycoprotein (GP) IIb/IIIa inhibition associated with percutaneous intervention, it would be unethical to subject patients to a placebo control in the catheterization laboratory. For those reasons, we returned to the clinical trials database and did a retrospective analysis of EPILOG and EPISTENT, the two studies that most appropriately reflect state-of-the-art intervention and abciximab use. We omitted EPIC, the original registration trial of high-risk angioplasty patients, because this study no longer reflects current recommendations regarding heparinization, abciximab administration, or groin care.

Management of esophageal gunshot wounds.

The records of 20 patients with gunshot wounds of the esophagus seen from 1973 through 1985 were reviewed. Nine perforations were cervical, 10 were thoracic, and 1 was abdominal. Because physical findings and plain roentgenograms lack specificity, a high index of suspicion based on the path of the bullet tract is essential for early diagnosis. Esophageal injury should especially be suspected when the bullet wound is transcervical or transmediastinal. Perforation was diagnosed by esophagoscopy in 9 patients, esophagography in 4, and surgical exploration in 7. Mean time from admission to operation was 3.8 hours. Associated injuries occurred frequently. Eighteen patients were treated by primary closure and wide drainage, and 2 were managed by esophageal exclusion. There were 2 perioperative deaths, both in patients with associated aortic injuries, and 1 late death, for an overall mortality of 15%. There was one postoperative leak following a cervical repair. No leaks occurred in patients having a thoracic repair. The findings indicate that esophageal perforation must be sought by a variety of methods. With prompt diagnosis and early operation, primary repair can be safely accomplished. When sepsis from esophageal leak is avoided, mortality and major morbidity are related to associated injuries.