Major noncardiac surgery following coronary stenting: When is it safe to operate?

Sharma, Arvind; Ajani, A.; Hamwi, Shadi M.; Maniar, Parimal B.; Lakhani, Sunil R.; Waksman, Ron; Lindsay, Joseph

doi:10.1002/ccd.20124

Cited by 181 publications

(124 citation statements)

References 33 publications

(22 reference statements)

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“…[10][11][12] From Mayo Clinic data, the cardiac risk was 3.8 to 7.1% during the first 6 weeks after stenting, but no event was seen in the patients who had surgery 6 to 8 weeks after stenting. 10) Schouten, et al reported that bare metal stent thrombosis occurred in 2.2% of patients who had noncardiac surgery 1 and 28 days after implantation; aspirin and clopidogrel had been withheld during surgery in patients with stent thrombosis.…”

Section: Discussionmentioning

confidence: 99%

“…Most available data about the risk of stent thrombosis in the perioperative period are derived from studies of bare metal stents. [10][11][12] Most authors and guidelines recommend that the surgery be avoided during the 12-month period of dual antiplatelet therapy after DES implantation, 13,14) however, there are limited data about the risk of perioperative thrombosis of DES. Therefore, we evaluated the incidence and the risk factors of DES thrombosis during the perioperative period.…”

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confidence: 99%

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Drug-Eluting Stent Thrombosis During Perioperative Period

et al. 2008

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SUMMARYRecently, the number of patients in whom a drug-eluting stent (DES) has recently been implanted and who need to undergo surgery or the most invasive procedure is increasing. However, there are limited data about the risk of perioperative thrombosis of DES. We evaluated the incidence and the risk factors of DES thrombosis during the perioperative period.Between January 2002 and December 2006, 141 patients who underwent surgery requiring discontinuation of a dual antiplatelet agent within 12 months of DES implantation were enrolled in one of the 3 study hospitals. We reviewed the clinical and procedural characteristics of the patients who developed stent thrombosis during the perioperative period.Stent thrombosis occurred in 7 cases (5.0%). The clinical outcomes of the patients with stent thrombosis were death in 5 cases and nonfatal MI in 2 cases. The patients with stent thrombosis were found to be older (64.2 ± 9.7 versus 71.7 ± 6.0 years, P = 0.045), to use a Taxus stent more frequently (36.6 versus 85.7%, P = 0.014), and to have a more prolonged period of discontinuation of clopidogrel (12.7 ± 10.0 versus 51.3 ± 33.2 days, P = 0.022) than the patients without stent thrombosis. Multivariate analysis revealed that 7 days or longer discontinuation of clopidogrel (OR 12.8, 95% CI 1.3-121.6, P = 0.021) and the use of a Taxus stent (OR 10.2, 95% CI 1.1-95.7, P = 0.043) were significant independent predictors of stent thrombosis during the perioperative period.A prolonged period of discontinuation of clopidogrel was associated with higher risk of stent thrombosis during the perioperative period. An earnest effort to continue antiplatelet therapy throughout the perioperative period can minimize the risk of stent thrombosis. (Int Heart J 2008; 49: 135-142)

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Section: Discussionmentioning

confidence: 99%

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confidence: 99%

Drug-Eluting Stent Thrombosis During Perioperative Period

et al. 2008

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“…Several retrospective series have disclosed very high complication rates when surgery is performed early after PCI: the combined rate of MI and death is 10-38% within 4 weeks after BMS, but decreases to 3.8% and 2.8% when surgery is performed at 2 and 3 months respectively [14,15,16] (Figure 1). After DES, the rate of adverse cardiac events is more continuous (5.9% up to 12 months) and drops to 3.3% beyond 1 year, but the mortality is high (average 35%) [17].…”

Section: Antiplatelet Agents and Coronary Revascularisationmentioning

confidence: 99%

“…The early interruption of dual antiplatelet therapy to allow major non cardiac surgery during the first month after PCI with BMS leads to a cardiac mortality up to 86%, whereas it is 5% when the treatment is maintained perioperatively [14]. In an observational study (192 patients), the incidence of DES thrombosis after early non cardiac surgery (13% urologic operations) was 31% among patients who stopped clopidogrel before the required delay, but 0% among those who continued dual antiplatelet therapy [20]; all patients with stent thrombosis died.…”

Section: Antiplatelet Discontinuation In the Surgical Settingmentioning

confidence: 99%

Urological Surgery and Antiplatelet Drugs After Cardiac and Cerebrovascular Accidents

Eberli

Chassot²,

Sulser

et al. 2010

Journal of Urology

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Context: The perioperative management of patients under dual antiplatelet therapy after myocardial infarction, cerebrovascular event or coronary stent implantation represents an increasingly frequent issue for urologists and anaesthesiologists.Objective: To assess the current scientific evidence and propose strategies concerning the management of urologic patients under antiplatelet therapy. A Medline & PubMed search was conducted for articles related to antiplatelet therapy after myocardial infarction, coronary stents and cerebrovascular events, and to the management of aspirin and/or clopidogrel in the context of surgery.Results: Early discontinuation of antiplatelet therapy in secondary prevention is associated with a high risk of coronary thrombosis, further increased by the hypercoagulable state induced by surgery. Aspirin has recently been recommended to be a lifelong therapy. Clopidogrel is mandatory for 6 weeks after myocardial infarction and bare-metal stents, and for 12 months after drug-eluting stents. Surgery must be postponed beyond these waiting periods, or be performed under dual antiplatelet therapy, because withdrawal therapy increases 5-10 times the risk of postoperative myocardial infarction, stent thrombosis or death. The shorter the waiting periods between revascularisation and surgery, the higher is the risk of adverse cardiac events. The risk of surgical haemorrhage is increased approximately 20% by aspirin and 50% by clopidogrel. Conclusions:The present review of the literature demonstrates that the risk of coronary thrombosis when antiplatelet agents are withdrawn before surgery is generally higher than the risk of surgical haemorrhage when antiplatelet agents are upheld. However, this issue has not yet been sufficiently evaluated in urologic patients and in many instances during urologic surgery the risk of bleeding might be exceedingly dangerous. In this problematic situation, a thorough dialogue between surgeon, cardiologist and anaesthesiologist is essential to determine all risk factors and to define the best possible strategy for each individual patient.

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“…al., 2002;Owens;Belkin et al, 2005;Pototski e Amenábar;et al, 2007). A interrupção pré-operatória de antiagregantes plaquetários, visando diminuir complicações hemorrágicas, pode desencadear um aumento rebote na ativação e agregação plaquetária, aumentando a probabilidade de um evento tromboembólico no paciente cardiopata (Sharma et al, 2004;Ferrari et al, 2005;Pfisterer et al, 2006;Krishman;Shenoy et al, 2008;Lillis et al, 2011;Park et al, 2012 (Floyd;Ferro, 2014), ou da inibição do receptor P2Y12 da adenosina difosfato (ADP), por meio do clopidogrel. As terapias mais utilizadas no tratamento e prevenção das DAC tem seu foco voltado para os ativadores ADP e TXA2 (Cheng, 2013).…”

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Extração dentária em pacientes com doença arterial coronariana em terapia antiplaquetária dual

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Major noncardiac surgery following coronary stenting: When is it safe to operate?

Cited by 181 publications

References 33 publications

Drug-Eluting Stent Thrombosis During Perioperative Period

Drug-Eluting Stent Thrombosis During Perioperative Period

Urological Surgery and Antiplatelet Drugs After Cardiac and Cerebrovascular Accidents

Extração dentária em pacientes com doença arterial coronariana em terapia antiplaquetária dual

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