Recent Drug-Eluting Stent on Ticagrelor with Acute Cholecystitis
A 68-year-old man had a non-ST-elevation myocardial infarction six weeks ago and underwent PCI with a second-generation drug-eluting stent to the proximal LAD. He takes aspirin 100 mg daily and ticagrelor 90 mg twice daily. He now presents with acute cholecystitis: temperature 38.6 °C, heart rate 108/min, blood pressure 105/62 mmHg, WCC 18 × 10⁹/L, and a positive Murphy sign. Ultrasound shows a distended gallbladder with wall thickening and pericholecystic fluid, but no common bile duct stones. Comorbidities are heart failure with reduced ejection fraction (EF 35%) and chronic kidney disease (eGFR 42 mL/min/1.73 m²). The surgeon requests laparoscopic cholecystectomy tomorrow morning; the cardiologist's note says "ticagrelor must not be stopped". There is no cholangiography suite available until next week, but interventional radiology can place a percutaneous cholecystostomy within 24 hours.
1. How would you weigh proceeding to laparoscopic cholecystectomy tomorrow against percutaneous cholecystostomy, and what would you recommend?
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Frame it correctly: this is urgent, not elective surgery. Tokyo Guidelines grade II cholecystitis (WCC >18 × 10⁹/L without organ dysfunction) in a patient with a very recent ACS and a newly implanted stent.
Risk of stopping or interrupting DAPT: stent thrombosis is highest in the first six months after ACS and carries 20–40% mortality. Current European and American guidance is to defer elective surgery for at least six months after a drug-eluting stent (twelve months after an ACS presentation) and to continue DAPT when urgent surgery cannot wait. He is at six weeks - squarely in the highest-risk window.
Risk of operating now: general anaesthesia, pneumoperitoneum and positioning in an EF 35% patient with sepsis and CKD; perioperative MI and acute kidney injury are real. Bleeding risk on dual antiplatelet therapy is increased but laparoscopic cholecystectomy is not a high-bleeding-compartment operation.
Risk of percutaneous cholecystostomy: it is a temporising measure, not a cure; catheter-related sepsis, dislodgement and recurrence are common, and he will still need a cholecystectomy later - but by then the high-risk stent period will have partly passed.
My recommendation: a joint decision with surgery, cardiology and intensive care. If he is improving on antibiotics with no organ dysfunction, I would favour percutaneous cholecystostomy plus antibiotics as a bridge, with laparoscopic cholecystectomy deferred for several months on continued DAPT. If he deteriorates - rising lactate, hypotension, peritonitis - the calculus changes and I would proceed to laparoscopic cholecystectomy on continued DAPT, accepting the bleeding risk.
2. If surgery goes ahead, how would you manage the antiplatelet regimen and what anaesthetic technique would you choose? Explain the neuraxial considerations.
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Antiplatelets: continue both aspirin and ticagrelor. Do not stop either without the cardiologist's explicit agreement, and document that agreement. If catastrophic bleeding occurs, platelet transfusion is the reliable reversal for ticagrelor; there is no specific antidote in routine use.
Neuraxial is off the table. ASRA guidance requires withholding ticagrelor for 5–7 days (and clopidogrel 5–7 days, prasugrel 7–10 days) before neuraxial instrumentation, and the same interval applies to catheter removal. A spinal or epidural here would risk spinal haematoma in a patient who cannot safely stop his antiplatelet. The same logic applies to deep, non-compressible peripheral blocks such as paravertebral.
What I would do instead: general anaesthesia with a supraglottic or endotracheal airway, short-acting agents (propofol/remifentanil or desflurane), and a superficial truncal block - rectus sheath or lateral TAP - under direct vision or ultrasound for opioid-sparing analgesia. These are in the abdominal wall and compressible, so the haematoma consequence of a small-vessel bleed is manageable.
Analgesia: paracetamol, careful tramadol or low-dose opioid, and avoid NSAIDs entirely given CKD, heart failure and antiplatelet therapy.
3. What intraoperative goals and monitoring would you set given an ejection fraction of 35%?
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Monitoring: invasive arterial line before induction; cardiac output monitoring (echo or pulse-contour); capnography; depth-of-anaesthesia and neuromuscular monitoring with TOF and sugammadex available; temperature; hourly urine output; arterial blood gases and lactate.
Haemodynamic goals:
- Maintain MAP ≥ 65 mmHg (higher if his baseline blood pressure demands it) and avoid tachycardia - heart rate control matters more than absolute pressure in ischaemic cardiomyopathy.
- Avoid fluid overload: sepsis plus EF 35% means he is intolerant of both hypovolaemia and salt and water loading; use small crystalloid challenges with echo assessment rather than fixed boluses.
- Pneumoperitoneum: insuffate slowly to ≤12 mmHg, accept a modest head-up tilt (≤15°) rather than full reverse Trendelenburg, and anticipate the fall in venous return on insufflation and the surge in systemic vascular resistance.
- Have a vasopressor infusion ready (noradrenaline) rather than relying on repeated boluses; avoid drugs that cause histamine release or marked myocardial depression.
Postoperative: high-dependency unit, continue DAPT without a gap, multimodal analgesia, early mobilization, and a documented plan for when definitive cholecystectomy can safely occur. Warn the team explicitly about the risk of perioperative MI and the need for immediate ECG and troponin if he develops chest pain, arrhythmia or unexplained hypotension.