Recent Drug-Eluting Stent on Ticagrelor Facing Acute Cholecystitis

The two risks pull in opposite directions and neither is trivial: stent thrombosis carries 20–40% mortality, and proceeding on full dual antiplatelet therapy in an inflamed, septic field carries a meaningful bleeding risk.

Key framing points:

• Stent risk is time-dependent. Stent thrombosis is highest in the first 30 days and declines substantially after 30–90 days with a second-generation drug-eluting stent. At 5 weeks she is past the peak but is definitely not in the low-risk window; guidelines advise deferring elective surgery for 6 months after ACS and preferably 6 months of uninterrupted dual therapy. Her surgery is not elective.
• Interrupting ticagrelor is not free. Stopping a P2Y12 inhibitor early is an independent predictor of stent thrombosis, and a 5-day washout in a septic patient is often not achievable and may not be safe.
• Continuing dual therapy is feasible for laparoscopic cholecystectomy, which is not a high-bleeding-compartment operation; bleeding is mostly from the cystic artery pedicle and controllable. It is my preference over a washout.
• Least-risk option: percutaneous cholecystostomy under local anaesthesia and ultrasound guidance, with antibiotics, continuing both antiplatelet agents without interruption. This controls the septic source without a general anaesthetic or a 5-day antiplatelet gap, and converts an emergency into an interval cholecystectomy at 6 months once dual therapy can be safely adjusted.

My decision: propose percutaneous cholecystostomy with cardiology and surgery on the same call, and reserve laparoscopic cholecystectomy for failure of drainage or clinical deterioration, in which case I would operate on full dual antiplatelet therapy rather than stop ticagrelor. I would not stop ticagrelor to make the surgery 'easier' five weeks after a proximal LAD stent.

Anaesthetic plan: general anaesthesia with a controlled airway, full dual antiplatelet therapy continued, and an aggressively prepared bleeding kit.

• Do not stop either agent. The clot that matters is in the LAD, not the cystic artery. Aspirin and ticagrelor both continue through the perioperative period.
• No neuraxial block. Spinal or epidural placement in a patient on a P2Y12 inhibitor risks spinal epidural haematoma; there is no indication to take that risk for a laparoscopic operation. A transversus abdominis plane or rectus sheath block is acceptable only with attention to bleeding, and is best avoided in sepsis with coagulopathy.
• Prepare for bleeding: two large-bore cannulae, cross-matched blood in theatre, rapid infuser, cell salvage, and a low threshold for activating the massive haemorrhage protocol. Tranexamic acid 15–20 mg/kg at induction. Ask the surgeon to control the cystic pedicle early and avoid a high-pressure pneumoperitoneum (keep insufflation ≤12 mmHg, which also limits diaphragmatic splinting and haemodynamic compromise).
• Haemodynamic management: avoid tachycardia and hypertension, which shear fresh platelet plugs; goal-directed fluids; noradrenaline for vasoplegia of sepsis rather than large fluid boluses; active warming.
• Avoid: NSAIDs and ketorolac (platelet inhibition plus renal risk), intramuscular injections, and blind nasogastric or difficult airway instrumentation that could cause mucosal bleeding.
• Platelet transfusion is not a reliable reversal for ticagrelor because the drug is reversible and binds plasma protein; transfused platelets are inhibited by circulating drug. Reserve it for life-threatening haemorrhage, and use fibrinogen/plasma based on viscoelastic testing rather than empiric product dumping.

Postoperatively: high-dependency care, continuation of dual antiplatelet therapy, serial haemoglobin, and a documented plan for the 6-month cardiology review.

The defensible record shows that the decision was shared, time-critical, and made with the relevant specialists informed - not that the anaesthetist made a unilateral call.

Practical steps:

1. Speak to a named cardiologist, not a note. If the on-call cardiologist is not the patient's usual physician, document the name, time, and advice. 'Cardiology not available' is not a plan; escalate to the consultant on call.
2. Speak to the surgeon explicitly about the bleeding risk of operating on dual antiplatelet therapy and about the percutaneous drainage alternative, and record their agreement or disagreement.
3. Consent the patient for both possibilities - drainage under local versus laparoscopic surgery under general anaesthesia on continued dual therapy - including the specific risks of stent thrombosis if antiplatelet therapy were interrupted, bleeding requiring transfusion or reoperation, conversion to open surgery, and the possibility of ICU admission. If she lacks capacity because of sepsis, document the capacity assessment and the best-interests discussion with the family.
4. Record the reasoning, not just the conclusion: the stent date and site, the platelet and renal function, the exact antiplatelet regimen and times of last doses, the risks quoted, who was consulted, and the trigger conditions that would change the plan (e.g., perforation, rising lactate, haemodynamic deterioration).
5. Handover in writing to ICU and to the surgical team, including the instruction that antiplatelet therapy must not be omitted by the ward.

An indefensible record is one that says 'continue DAPT per cardiology' without evidence of a conversation, or one in which a drug was held without a documented risk assessment and a plan for the stent.