Perioperative Management of Patients With Drug-Eluting Stents

Abstract

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.

Bleeding Is Rarely Good for You

“…We know that noncardiac surgery in the first 4 to 6 weeks after coronary stenting is associated with a markedly increased risk of in-stent thrombosis. 13 We also know that longer dual-agent antiplatelet therapy is needed with drug eluting stents, which then are probably somewhat better than bare metal stents. 14 But, despite sensible interim recommendations based on nonrandomized data, 12,13 we really do not know at all how best to manage these patients through noncardiac surgery, be they soon or long after a bare metal or drug-eluting stent.…”

“…13 We also know that longer dual-agent antiplatelet therapy is needed with drug eluting stents, which then are probably somewhat better than bare metal stents. 14 But, despite sensible interim recommendations based on nonrandomized data, 12,13 we really do not know at all how best to manage these patients through noncardiac surgery, be they soon or long after a bare metal or drug-eluting stent. It simply is not appropriate for us to keep tap dancing with recommendations whose scientific basis is no more sound than a variety of treatment guidelines that have long since been abandoned based on careful randomized trials.…”

“…First, we have reasonable guidelines to follow for now, even though they are supported by weak data. 12,13 Second, I see no evidence that diminished oxygen-carrying capacity itself causes postoperative stroke. Rather, it seems much more likely that the risk of perioperative stroke is related to hypotension, which often can be caused by bleeding.…”

II Diretriz de Avaliação Perioperatória da Sociedade Brasileira de Cardiologia

“…The strategy that seems more reasonable in this situation is using AAS throughout the perioperative period, with thienopyridine discontinuation 5 days before surgery and reintroduction as early as possible, ideally before the patient completes 10 days without this medication 197 (Degree of Recommendation I, Level of Evidence C). In cases with low estimated bleeding risk inherent to the surgical procedure, it is possible to consider perform this surgery in the presence of dual antiplatelet therapy 198 Degree of Recommendation IIa, Level of Evidence C) 198 . However, this strategy does not provide the same protection when compared to the ideal length of time and, therefore, surveillance for ischemic events should be maintained.…”

Unfractionated Heparin during the Interruption of Antiplatelet Therapy for Non-cardiac Surgery after Drug-eluting Stent Implantation

“…The interruption of antiplatelet therapy (APT) for surgery is considered to be one of the main reasons for the increased risk (2)(3)(4)(5). The optimal perioperative manage- Figure. Heparin administration according to the local institutional practice guideline.…”