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  • Stents implanted in >80% of percutaneous coronary intervention (PCI) following balloon angioplasty to decrease acute and long-term restenosis
  • However, until reendothelialization, the risk of thrombosis is increased, and the patient must be maintained on dual antiplatelet therapy (typically ASA + clopidogrel [Plavix®])

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Table Graphic Jump Location
Table 22-1 Duration of Antiplatelet Therapy Following PCI or Stent Implantation
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The issue is the balance between:

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  • Bleeding risk of proposed surgery (to be assessed by surgeon and anesthesiologist) under antiplatelet therapy:
    • Low risk (minor ophthalmologic, endoscopic, superficial procedures, dermatologic)
    • Intermediate risk (orthopedic, urologic, uncomplicated abdominal, thoracic, or head and neck surgeries)
    • High risk (aortic, vascular, anticipated prolonged surgical procedures associated with large fluid shifts or blood loss, emergency procedure)
    • Also consider the site of surgery: intracranial and some ophthalmologic procedures where even minor bleeding is intolerable
  • Likelihood and importance of possible stent thrombosis (assess in conjunction with a cardiologist, ideally the one who implanted the stent). Higher risk if:
    • Noncardiac surgery <6 weeks for BMS and <1 year for DES
    • Types of lesions:
      • Ostial lesions
      • Bifurcation lesions
      • Small (<3 mm) stent diameter
      • Multiple or long (>18 mm) lesions, overlapping stents
    • DM
    • Renal insufficiency
    • Advanced age
    • Low EF
    • Prior brachytherapy (intracoronary irradiation to prevent reocclusion)
    • Indication for stenting was acute MI or acute coronary syndrome

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In most cases, the risk of thrombosis if antiplatelet therapy is interrupted is higher than the added risk of bleeding (even if transfusion is needed).

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  • Discuss whether surgery can be safely performed in a hospital where a cath lab is not immediately available (if that is the case)
  • If emergent surgery: proceed under antiplatelet therapy; manage bleeding as needed
  • If semi-urgent surgery:
    • Implant BMS
    • Complete dual antiplatelet therapy as indicated (30–45 days)
    • Then proceed to surgery on ASA
  • If elective surgery:
    • Patient with DES:
      • Usual case: defer procedure until completion of appropriate course of dual antiplatelet therapy (12 months), and then perform procedure on ASA:
        • If ASA is not recommended for that type of surgery (e.g., spinal fusion), discontinue ASA preoperatively and restart as soon as possible
      • If patient is still taking clopidogrel after 12 months (because deemed high thrombosis risk by cardiologist):
        • Discontinue clopidogrel and have surgery on ASA, if possible; restart clopidogrel as soon as possible
    • Patient with BMS:
      • Delay procedure for 30–45 days (until completion of dual antiplatelet therapy), and then perform procedure on ASA if possible
      • If ASA not recommended, d/c ASA preoperatively and resume postoperatively as soon as possible

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Table Graphic Jump Location
Table 22-2 Management Recommendation Depending on Risk of Surgical Bleeding and Risk of Stent Thrombosis

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