Perioperative Management of Patients With Coronary Stents

Brilakis, Emmanouil S.; Banerjee, Subhash; Berger, Peter B.

doi:10.1016/j.jacc.2007.02.046

Cited by 186 publications

(113 citation statements)

References 51 publications

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“…Nevertheless, if coronary stenting occurs and LC surgery must be performed, the following options exist: (I) delay of the oncologic operation; (II) lung resection under cessation of dual anti-platelet therapy or under anti-coagulative treatment by inducing increased risk for perioperative bleeding; and (III) application of stereotactic radiotherapy (105)(106)(107).…”

Section: Discussionmentioning

confidence: 99%

Management and postoperative outcome in primary lung cancer and heart disease co-morbidity: a systematic review and meta-analysis

Bablekos¹,

Analitis²,

Michaelides³

et al. 2016

Ann. Transl. Med.

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Background: Co-morbidity of primary lung cancer (LC) and heart disease (HD), both requiring surgical therapy, characterizes a high risk group of patients necessitating prompt diagnosis and treatment. The aim of this study is the review of available evidence guiding the management of these patients.Methods: Postoperative outcome of patients operated for primary LC (first meta-analysis) and for both primary LC and HD co-morbidity (second meta-analysis), were studied. Parameters examined in both meta-analyses were thirty-day postoperative mortality, postoperative complications, three-and five-year survival probabilities. The last 36 years were reviewed by using the PubMed data base. Thirty-seven studies were qualified for both meta-analyses. Results:The pooled 30-day mortality percentages (%) were 4.16% [95% confidence interval (CI): 2.68-5.95](first meta-analysis) and 5.26% (95% CI: 3.47-7.62) (second meta-analysis). Higher percentages of squamous histology and lobectomy, were significantly associated with increased (P=0.001) and decreased (P<0.001) thirty-day postoperative mortality, respectively (first meta-analysis). The pooled percentages for postoperative complications were 34.32% (95% CI: 24.59-44.75) (first meta-analysis) and 45.59% (95% CI: 35.62-55.74) (second metaanalysis). Higher percentages of squamous histology (P=0.001), lobectomy (P=0.002) and p-T1 or p-T2 (P=0.034) were associated with higher proportions of postoperative complications (second meta-analysis). The pooled threeand five-year survival probabilities were 68.25% (95% CI: 45.93-86.86) and 52.03% (95% CI: 34.71-69.11), respectively. Higher mean age (P=0.046) and percentage lobectomy (P=0.009) significantly reduced the five-year survival probability.Conclusions: Lobectomy and age were both accompanied by reduced five-year survival rate. Also, combined aorto-coronary bypass grafting (CABG) with lobectomy for squamous pT1 or pT2 LC displayed a higher risk of postoperative complications. Moreover, medical decision between combined or staged surgery is suggested to be individualized based on adequacy of coronary arterial perfusion, age, patient's preoperative performance status (taking into account possible co-morbidities per patient), tumor's staging and extent of lung resection.

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Section: Discussionmentioning

confidence: 99%

Management and postoperative outcome in primary lung cancer and heart disease co-morbidity: a systematic review and meta-analysis

Bablekos¹,

Analitis²,

Michaelides³

et al. 2016

Ann. Transl. Med.

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“…In the event of an emergency surgery with a high bleeding risk necessitating interruption of DAPT, it is recommended that clopidogrel should be restarted with a loading dose of 300 or 600 mg (in higher risk patients) as soon as possible after surgery if postoperative bleeding has stopped [12,13]. The surgical procedure should ideally be performed in centers with 24-hour interventional cardiology coverage [14]. While platelet transfusion may be necessary for excessive bleeding after surgery, the role of prophylactic platelet transfusion has not been well studied.…”

Section: Discussionmentioning

confidence: 99%

Perioperative Cardiac Stent Thrombosis Versus Bleeding: A Clinical Dilemma in Trauma Patients

Omonele¹,

Robert²

2018

Int J Anesthetic Anesthesiol

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Heart disease is prevalent in current patient population at an increasing level. Some of these patients have had interventions such as stent placements to improve quality of life and are started on antiplatelet therapy for a definite period of time or indefinitely based on their risk factors, comorbidities or type of stents placed. When these patients present to the hospital with major trauma, the surgical and anesthetic management threads a delicate line between protection of the stents and preventing life-threatening bleeding. We present a 66-year-old patient on dual antiplatelet therapy (DAPT) admitted for femur fracture with arterial injury after an auto-pedestrian collision. He was in hemorrhagic shock. A decision was made to stop his DAPT and taken to the operating room for intramedullary nailing of the left femur the next day. He tolerated the procedure with one episode of intraoperative hypotension responsive to vasoactive agents. He received four units of packed red blood cells (PRBCs) and two units of fresh frozen plasma (FFP) but suffered a perioperative Non-ST segment elevation myocardial infarction (NSTEMI). He was taken to cardiac catheterization lab the next day and revascularized. This was a high-risk patient with significant bleeding from the accident potentially justifying the need to stop the DAPT; however, this action may have contributed to his myocardial infarction. Other considerations include a preoperative/posttrauma MI that was not diagnosed prior to surgery.

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“…Percutaneous coronary intervention and cardiac surgical services should also be available, as emergency revascularisation is essential should a stent thrombosis occur. 40,58 There is no place for improvisation or delay.…”

Section: Postoperative Carementioning

confidence: 99%

Do percutaneous coronary interventions protect the surgical patient?

Howard-Alpe

Bono

Hudsmith

et al. 2008

Southern African Journal of Anaesthesia and Analgesia

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The number of percutaneous coronary interventions (PCI) performed annually has increased rapidly over the last two decades. Coronary angioplasties are now commonly complemented with the insertion of coronary artery stents. Initially bare metal stents (BMS) were developed with drug-eluting stents (DES) subsequently being introduced. Drug-eluting stents reduce in-stent restenosis at the cost of prolonged anti-platelet therapy. While observational studies suggest that coronary artery bypass graft surgery protects against perioperative cardiac events in non-cardiac surgery, no such evidence exists for PCI. In order to prevent stent thrombosis, patients need to receive dual anti-platelet therapy (generally aspirin and clopidogrel) for four to six weeks with BMS, and at least one year with DES. Patients on dual anti-platelet therapy are at risk of severe bleeding during surgery. However, withdrawal of dual anti-platelet therapy is associated with the risk of stent thrombosis. The risk of cardiac complications seems to exceed the risk of bleeding, and maintenance of dual anti-platelet therapy is advocated whenever possible. Surgery in closed cavities (neurosurgery, intraocular surgery) necessitates the withdrawal of dual anti-platelet therapy. There is a significant risk of perioperative complications in patients who have DES, or recently inserted BMS, and consequently surgery should not be performed without a discussion involving the surgeon, cardiologist, anaesthetist, and the patient. IntroductionOver the past thirty years there have been major advances in the management of patients with coronary artery disease. These have included life style changes, recently complemented in some countries by the ban of smoking in public places, the development of drug strategies including beta-adrenoceptor blockers, angiotensin-converting enzyme inhibitors, statins, aspirin, thrombolysis and early myocardial revascularisation. Coronary artery bypass graft (CABG) surgery has also evolved. Internal mammary arteries and subsequently radial arteries have been utilised alone or in addition to saphenous vein grafts to revascularise the coronary circulation, and CABG surgery may be performed with or without cardiopulmonary bypass. Finally, there has been the rapid development of percutaneous coronary interventions. These advances resulted in a 65% decrease in the death rate among patients below the age of 65 over the period 1970-2002.

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Perioperative Management of Patients With Coronary Stents

Cited by 186 publications

References 51 publications

Management and postoperative outcome in primary lung cancer and heart disease co-morbidity: a systematic review and meta-analysis

Management and postoperative outcome in primary lung cancer and heart disease co-morbidity: a systematic review and meta-analysis

Perioperative Cardiac Stent Thrombosis Versus Bleeding: A Clinical Dilemma in Trauma Patients

Do percutaneous coronary interventions protect the surgical patient?

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