Use of drug-eluting balloon coronary intervention prior to living donor kidney transplantation
© Kammerer et al.; licensee BioMed Central Ltd. 2014
Received: 30 January 2014
Accepted: 19 August 2014
Published: 1 September 2014
Kidney transplantation is the gold standard of therapy in patients with terminal renal insufficiency. Living donor transplantation is a well-established option in this field. Enlarging the donor’s pool implicates the acceptance of an increased rate of comorbidities. Among them, coronary artery disease is a growing problem. An increasing number of patients, undergoing living donation, receive antiplatelet therapies due to coronary disease.
Here we report about the perioperative treatment with a drug-eluting balloon in a patient with major cardiac risk factors who underwent kidney transplantation.
At the current time no recommendation can be given for the routine use of drug-eluting balloons.
Kidney transplantation is still the gold standard of therapy in patients with terminal renal insufficiency. Thus, the criteria for candidates for kidney transplantation have been weakened over the last decades to offer this option to a larger group of patients with otherwise worse outcome. Living donor transplantation is becoming more and more a well-established option in this field. However, clinicians will have to deal more and more with patients suffering from a number of relevant co-morbidities. Especially coronary artery disease (CAD) is becoming a growing problem in perioperative medicine as current standard treatment options (i.e. coronary stenting) often go along with long lasting antiaggregation protocols [1, 2]. Various aspects of antiaggregation after percutaneous transluminal coronary angioplasty (PTCA) are partly discussed controversially . Dual platelet inhibition after placement of drug eluting or bare metal stents may lead to considerable bleeding complications during the surgical intervention [4, 5]. By contrast an interruption of antiplatelet therapy results in a significant increase of perioperative cardiac complications [6, 7]. At the same time, more and more drug-eluting stents are used by interventional cardiologists. To minimise this problem a bipartite intervention using a drug-eluting balloon is a possible alternative [8–10]. Until now, no investigations or case reports are published examining the use of drug-eluting balloons in a perioperative setting. Here we report about the perioperative treatment with a drug-eluting balloon in a kidney transplant patient with major cardiac risk factors.
A 66-year-old man (height 172 cm, weight 92 kg) presented with diabetic nephropathy for planned living donor kidney transplantation. He suffered from CAD, hypertension, hypercholesterolemia, insulin dependent diabetes mellitus II and a chronic obstructive pulmonary disease. He had undergone coronary artery bypass surgery in a different hospital 7 months before (left internal mammary artery (LIMA) to left anterior descending (LAD) and saphenous vein graft to the ramus diagonalis). The ramus circumflexus (RCX) was not accessible to revascularization during bypass operation according to the documents of the different hospital. The LAD was supplied with a drug-eluting stent three years before. The RCX was supplied with a bare-metal stent one year before and, because of an in-stent restenosis, 5 month before with a Genous stent in a different hospital. Additionally another Genous stent was placed distally to the previous stent area.
The perioperative management of patients undergoing non-cardiac surgery in the age of increasing percutaneous coronary intervention is a major problem. The present treatment is based on the recommendations of the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) [11, 12]. Additionally, guidelines of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA) were published in 2009 .
Patients, receiving a surgical intervention within the first 35 days after coronary stent implantation, have an increased risk of stent thrombosis with consecutively increased morbidity and mortality . Hence, it is recommended to delay elective interventions about at least 6 weeks (after bare metal stent)  or 12 months (after drug eluting stents) . If this is no opinion in urgent cases or emergency surgery, an individual, patient adapted strategy has to be carried out. In the present case, the living donor transplantation was called off twice because of an infect exacerbation of the donor, who was now in a good condition. After interdisciplinary discussion the renewed in-stent restenosis was treated by a drug-eluting balloon, followed by anticoagulation with tirofiban and aspirin until surgery. Eptifibatide  or tirofiban  is a possible alternative to clopidogrel. If dual antiplatelet therapy is not possible on account of high bleeding risk, for example in neurosurgery, clopidogrel can be stopped 5–7 days before surgery under current medication with aspirin . Instead of stenting with BMS or DES a pure balloon angioplasty should be performed under specific circumstances . These specific circumstances are, however, not specified in the guideline. Thus, preoperative PTCA without stenting seems to be a good “bridging strategy” for patients with intermediate urgency of the planned operation. A recently increasingly used alternative is an intervention with drug eluting balloons [8–10]. Several clinical investigations underline the meaning of drug-eluting balloons in the treatment of instent stenosis [19–21]. This new option may even foster the attitude towards the mentioned “bridging strategy”.
In our opinion and based on this report the use of a drug-eluting balloon intervention should only be performed under special circumstances: the whole team has to be aware of the potential risk of perioperative myocardial ischemia, and the option of immediate coronary re-intervention by a cardiologist familiar with the respective case has to be well prepared. In the present case it was even the same cardiologist who had performed the initial intervention.
This underlines the meaning of an interdisciplinary approach in the perioperative care of cardiac patients which concerns not only surgeons and anaesthesiologists, but in particular also the treating cardiologists.
On account of the insufficient data at the current time from our point of view no recommendation can be given for the routine use of drug-eluting balloons.
Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
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