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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\u003Cp id=\u0022p-1\u0022\u003EThe OUTSIDE START Cilostazol Bridge Study shows that the majority of patients who were required to discontinue dual antiplatelet therapy prior to surgery can be successfully bridged through surgery with cilostazol, with no major cardiac events in patients who are adequately bridged, provided that patients receive adequate cilostazol dosing and resume dual antiplatelet therapy within 24 to 48 hours postoperatively.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Eantiplatelet\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ebridging\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecilostazol\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Edrug-eluting stent\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Edual antiplatelet therapy\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Emajor cardiac events\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EMACE\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Epaclitaxel-eluting stent\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Esurgery\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ethrombosis\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EOUTSIDE START\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecardiology \u0026amp; cardiovascular medicine clinical trials\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Einterventional techniques \u0026amp; devices\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\u003Cp id=\u0022p-2\u0022\u003EDual antiplatelet therapy (DAPT) with a P2Y\u003Csub\u003E12\u003C\/sub\u003E inhibitor plus aspirin decreases drug-eluting stent (DES) thrombosis [Mauri L et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E. 2014]. Each year, approximately 5% to 10% of patients with a DES must interrupt DAPT to reduce perioperative bleeding. Premature discontinuation of DAPT, especially during the first postoperative year, results in stent thrombosis rates of 10% to 35%, inversely related to duration after stent placement [Moussa ID, Colombo A. \u003Cem\u003ECatheter Cardiovasc Interv\u003C\/em\u003E. 2009; van Kuijk JP et al. \u003Cem\u003EAm J Cardiol\u003C\/em\u003E. 2009]. The highest stent thrombosis rates have been observed in patients with a paclitaxel-eluting stent (PES) during DAPT discontinuation, leading to increased major adverse cardiac events (MACEs) for prolonged durations, up to 30 months poststenting [Garratt KN et al. \u003Cem\u003ECirculation\u003C\/em\u003E. 2015].\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003ECurrently, there is no consensus on the best bridging strategy for patients with a DES discontinuing DAPT preoperatively [Kern MJ et al. \u003Cem\u003ECatheter Cardiovasc Interv\u003C\/em\u003E. 2014]. DES bridging has been attempted with aspirin, heparin, glycoprotein IIb\/IIIa inhibitors, low molecular weight heparins, and intravenous cangrelor, but success has been limited. Cilostazol, a phosphodiesterase inhibitor\u2013type 3 that reversibly inhibits platelet activation and aggregation has shown promise as a third antiplatelet agent for high-risk patients and, given its shorter half-life, may be a consideration for perioperative bridging.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EThe OUTSIDE START Cilostazol Bridge Study, presented by Charles L. Laham, MD, Holy Family Memorial Hospital, Manitowoc, Wisconsin, USA, was a retrospective analysis conducted in patients who required surgery during the first 6 to 12 months after PES placement and discontinued DAPT. The analysis included consecutive patients who were bridged with cilostazol from 2 weeks to 60 months after a PES placement over an 8-year period.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EThe patients stopped DAPT 8 days before surgery and started cilostazol 100 mg BID on the seventh day preoperatively. Two dosing regimens of cilostazol 1300 mg were used to reduce the risk and degree of perioperative bleeding. Patients undergoing surgery with a low to moderate risk of bleeding had a goal of cilostazol 1300 mg, which they discontinued 24 to 30 hours before surgery. DAPT was resumed 12 to 24 hours after surgery. The goal for patients undergoing high-bleeding-risk surgery was cilostazol 1000 mg, which they stopped 54 to 60 hours prior to surgery. They restarted DAPT 24 to 36 hours after surgery. The primary end points were perioperative bleeding and MACE (cardiac death, myocardial infarction, or urgent revascularization) within the bridged period and up to 1 month after surgery.\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EA total of 108 patients with \u2265\u20051 PES who underwent 183 consecutive surgeries stopped DAPT and were bridged by cilostazol (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E). Of these, 104 (57%) surgeries were bridged with cilostazol 1300 mg, 60 (32%) with cilostazol 1000 mg, and 10 (5.5%) with 650 to 900 mg. A total of 171 surgeries were adequately bridged with \u0026gt;\u2005600 mg of cilostazol. The remaining 12 patients received an inadequate preoperative dose of 0 to 600 mg cilostazol and failed to resume DAPT postoperatively. No MACE occurred among patients who were successfully bridged with cilostazol. Among patients who were not adequately bridged perioperatively, 1 MACE occurred in the first year, and of note, 3 occurred beyond 12 months, of which 1 occurred up to 40 months post-PES stent placement. The study results are shown in \u003Ca id=\u0022xref-table-wrap-1-2\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E.\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/16675\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/16675\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16675\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \u003Cp id=\u0022p-7\u0022 class=\u0022first-child\u0022\u003EOUTSIDE START Cilostazol Bridge Study: 8-Year Results, No. (%)\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-17\u0022\u003EPerioperative cilostazol for DES bridging is feasible in patients at the highest risk of stent thrombosis with PES and completely off DAPT. No MACE or bleeding other than minor nuisance bleeding was reported in patients who were successfully bridged with cilostazol. Dr Laham concluded that this was a clinically driven hypothesis-generating feasibility study. The results should be verified in controlled trials using current-generation DES and bare metal stents with antiplatelet agents in current use.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2015 SAGE Publications\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/15\/10\/8.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzll01\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzll01\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}