Thrombosis of a drug-eluting stent (DES) is a catastrophic complication. The risk of stent thrombosis (ST) is increased in the perioperative setting and is strongly associated with the cessation of antiplatelet therapy. This article reviews the perioperative management of patients with DES with a clinical focus on the perioperative use of antiplatelet therapy. Cessation of dual antiplatelet therapy is the single most significant predictor of perioperative ST. Available data on perioperative management of patients with DES are limited, and recommendations are therefore limited. To avoid ST with DES, aspirin and thienopyridines should ideally be continued throughout surgery. In spite of the increased risk of bleeding, this strategy is acceptable in many types of invasive surgical procedures with no change in outcome. However, if the bleeding risk outweighs the risk of ST, other potential strategies include treatment with aspirin alone, "bridging therapy" with aspirin and a glycoprotein IIb/IIIa inhibitor and/or heparin, and "bridging therapy" without aspirin. Novel antiplatelet therapies are promising and potentially valuable in the perioperative management of patients with DES. Maintaining dual antiplatelet therapy is the mainstay of perioperative ST prevention. However, short-term discontinuation of thienopyridines might be associated with relatively low risk if aspirin therapy is maintained perioperatively.

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