Chapter 22. Patient with a Stent (or Following PCI)

• 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®])

The issue is the balance between:

• 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

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).

• 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