Management of patients with coronary stents in elective thoracic surgery (original) (raw)
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EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology, 2014
Optimal perioperative antiplatelet therapy in patients with coronary stents undergoing surgery still remains poorly defined and a matter of debate among cardiologists, surgeons and anaesthesiologists. Surgery represents one of the most common reasons for premature antiplatelet therapy discontinuation, which is associated with a significant increase in mortality and major adverse cardiac events, in particular stent thrombosis. Clinical practice guidelines provide little support with regard to managing antiplatelet therapy in the perioperative phase in the case of patients with non-deferrable surgical interventions and/or high haemorrhagic risk. Moreover, a standard definition of ischaemic and haemorrhagic risk has never been determined. Finally, recommendations shared by cardiologists, surgeons and anaesthesiologists are lacking. The present consensus document provides practical recommendations on the perioperative management of antiplatelet therapy in patients with coronary stents u...
Perioperative antiplatelet therapy in patients with coronary stents
International Journal of Cardiology, 2010
. Immunoinflammatory activity and CA125 status. IL-1β: interleukine 1 beta; IL-6: interleukine 6; TNFα: tumour necrosis factor alpha; CA125: antigen carbohydrate 125. 132 consecutive nonselected patients admitted for acute heart failure (mean age 76 ± 13 years; 48.5% and 59.1% were female and exhibited LVEF ≥ 45%, respectively). (A. Roguin).
British Journal of Anaesthesia, 2004
In this report we present the case of a 77-yr-old man who underwent resection of the upper lobe of the left lung for a carcinoma, six weeks after percutaneous transluminal coronary angioplasty (PTCA) with stenting of the left anterior descending (LAD) and circum¯ex coronary arteries. Antiplatelet therapy with clopidogrel was interrupted two weeks before surgery to allow for epidural catheter placement and to minimize haemorrhage. The surgical procedure was uneventful. In the immediate postoperative period, however, the patient suffered severe myocardial ischaemia. Emergency coronary angiography showed complete thrombotic occlusion of the LAD stent. In spite of successful recanalization, reinfarction occurred and the patient died in cardiogenic shock. Prophylactic preoperative coronary stenting may put the patient at risk of stent thrombosis if surgery cannot be postponed for three months. In such cases, other strategies such as perioperative b-blockade for preoperative cardiac management should be considered. Br J Anaesth 2004; 92: 743±7
Perioperative Management of Patients With Drug-Eluting Stents
JACC: Cardiovascular Interventions, 2010
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.
Incremental Risk of Prior Coronary Arterial Stents for Pulmonary Resection
The Annals of Thoracic Surgery, 2013
Background. Many patients requiring lung cancer resection have concomitant coronary artery disease. Preoperative coronary artery stenting has been associated with increased risk of cardiac events after noncardiac surgery. Our aim was to determine the incidence of major adverse cardiac events (MACE) in patients undergoing pulmonary resection for lung cancer after percutaneous coronary stenting.
Vascular Health and Risk Management, 2010
The management of patients scheduled for surgery with a coronary stent, and receiving 1 or more antiplatelet drugs, has many controversies. The premature discontinuation of antiplatelet drugs substantially increases the risk of stent thrombosis (ST), myocardial infarction, and cardiac death, and surgery under an altered platelet function could also lead to an increased risk of bleeding in the perioperative period. Because of the conflict in the recommendations, this article reviews the current antiplatelet protocols after positioning a coronary stent, the evidence of increased risk of ST associated with the withdrawal of antiplatelet drugs and increased bleeding risk associated with its maintenance, the different perioperative antiplatelet protocols when patients are scheduled for surgery or need an urgent operation, and the therapeutic options if excessive bleeding occurs.
Journal of Hospital Medicine, 2007
BACKGROUND: Drug-eluting coronary stents (DESs) pose a challenge in the perioperative period. Sirolimus and paclitaxel may inhibit reendothelialization of the traumatized vessel, making it vulnerable to platelet-mediated thrombosis. Given the anecdotal evidence and case series suggesting that DESs may be more vulnerable to thrombosis on discontinuation of antiplatelet agents than are bare-metal stents, we sought to quantify this risk. METHODS: We linked the Cleveland Clinic Heart Center database with the Cleveland Clinic Internal Medicine Preoperative Assessment Consultation and Treatment (IMPACT) Center database to identify all patients who had undergone DES placement at the Cleveland Clinic and subsequently were evaluated for noncardiac surgery between July 2003 and July 2005. Outcome measures included 30-day rate of postoperative myocardial infarction (MI), DES thrombosis, major bleeding, and all-cause mortality. RESULTS: We identified 114 patients who underwent noncardiac surgery a median of 236 days (IQR 125-354) after stent placement. Forty-five patients (40%) underwent surgery within 180 days of stenting, 15 of whom (13%) underwent surgery within 90 days of stenting. Eighty-eight patients (77%) discontinued all antiplatelet agents a median of 10 days before surgery. No patients died. Two patients (1.8%, 95% CI 0.5%-6.2%) suffered postoperative MIs, but postoperative catheterization showed neither had DES thrombosis (0%, 95% CI 0%-3.3%). One patient developed major bleeding (0.9%, CI 0.2%-4.8%). CONCLUSIONS: These data suggest that the overall risk of stent thrombosis is low in low-risk noncardiac surgery patients with DESs, particularly those who have undergone at least 180 days of antiplatelet therapy, even after complete discontinuation of antiplatelet agents.
Cleveland Clinic Journal of Medicine, 2006
Background: Drug-eluting stents (DES) pose a challenge in the perioperative setting. Sirolimus and paclitaxel not only inhibit neointimal hyperplasia, but may also inhibit re-endothelialization of the traumatized vessel, making it vulnerable to platelet-mediated thrombosis. Aspirin (ASA) and clopidogrel (CP) are recommended by the FDA for sirolimus stents and paclitaxel stents for 3 and 6 months, respectively. We conducted a retrospective cohort study to examine the safety of discontinuing antiplatelet therapy for elective noncardiac surgery in patients with recent DES placement. Methods: We cross-matched the Cleveland Clinic (CC) Heart Center database with the CC Internal Medicine Preoperative Assessment, Consultation, and Treatment (IMPACT) Center database to identify all patients who underwent placement of a DES at CC and subsequently underwent elective noncardiac surgery at CC between July 2004 and July 2006. Outcome measures included 30-day rates of postoperative myocardial infarction (MI), DES thrombosis, major bleeding, and all-cause mortality. Results: We identified 114 patients who underwent noncardiac surgery a median of 236 days [IQR, 125 to 354] after stent placement. Eighty-eight patients (77%) underwent discontinuation of all antiplatelet agents. ASA was stopped a median of 10 days [8 to 12] preoperatively, and CP was discontinued 10 days [8 to 13] preoperatively. Thirteen patients (11.4%) had CP discontinued within 90 days of the stenting and 35 patients (30.7%) had CP discontinued within 180 days of the stenting. No patients died. Two patients (1.75%; 95% CI, 0.48% to 6.17%) developed MI on postoperative days 3 and 7, respectively. Patient 1 had three DES placed and had ASA and CP stopped 33 days after stenting (17 days preoperatively). Patient 2 had one DES placed and had clopidogrel stopped 287 days after stenting (7 days preoperatively). Neither had DES thrombosis by postoperative catheterization. Another patient developed major bleeding (0.87%; 95% CI, 0.16% to 4.8%). Conclusion: This is the first series to date looking at the safety of discontinuing antiplatelet therapy in patients with DES scheduled for noncardiac surgery. Our sample was small and most patients underwent surgery > 180 days from stenting. The absence of DES thrombosis and the low rate of postoperative MI may suggest that preoperative discontinuation of antiplatelet agents in patients with DES could be feasible after 6 months, in preparation for surgery. Larger trials are necessary, however.