Catastrophic Outcomes of Noncardiac Surgery Soon After Coronary Stenting
June 1, 2000 3 minutes read
Catastrophic Outcomes of Noncardiac Surgery Soon After Coronary Stenting
abstract & commentary
Synopsis: Elective noncardiac surgery should be postponed for 2-4 weeks after coronary stenting to complete the intensive antiplatelet regimen, avoiding in-stent thrombus or excessive bleeding.
Source: Kaluza GL, et al. J Am Coll Cardiol 2000; 35:1288-1294.
Frequently, patients who are evaluated for the risk of noncardiac surgery undergo coronary revascularization to reduce their risk of a perioperative cardiac event. However, little is known about the protective value of coronary stenting. Thus, Kaluza and colleagues retrospectively reviewed the outcomes of 40 patients who had stents placed less than six weeks prior to noncardiac surgery. The surgical procedures included carotid endarterectomy in 12; aortic aneurysm resection in nine; peripheral vascular surgery in eight; and other surgeries requiring general anesthesia in the remainder. All 40 patients received aspirin before stenting and at least one dose of ticlopidine after stenting, but the continuation of antiplatelet drugs was variable. Perioperative major events included seven myocardial infarctions (MI), 11 bleeding episodes requiring transfusion, and eight deaths. All but three of these events occurred in patients who had surgery less than 14 days from stenting. Time from stenting to surgery seemed to be the major determinant of outcome. The mortality rate in the 25 patients operated within two weeks of stenting was 32%. MI, presumably due to in-stent thrombosis, accounted for most of the deaths. Ticlopidine and aspirin were discontinued before surgery and for a few days afterward in most patients and seemed unrelated to the subsequent events. Kaluza et al conclude that elective noncardiac surgery should be postponed for 2-4 weeks after coronary stenting to complete the intensive antiplatelet regimen, avoiding in-stent thrombus or excessive bleeding.
Comment by Michael H. Crawford, MD
This study has several limitations. It is retrospective, uncontrolled, and involves a heterogeneous population. A variety of stents were used and the surgical procedures ranged from major (aortic aneurysm) to relatively minor (femoral embolectomy). However, the results are robust, with a 32% mortality in those operated within two weeks of stenting. Also, the results are biologically plausible. As Kaluza et al point out, stent implantation is a double-edged sword. If antiplatelet drugs are withheld, the risk of in-stent thrombosis is increased and if they are not, major bleeding can occur. In their experience, both were often fatal. Thus, they strongly recommend delaying elective noncardiac surgery until the full course of intensive antiplatelet therapy is over and do not believe that a randomized trial is necessary.
Current recommendations for ticlopidine and aspirin post-stenting call for 30 days in patients at high risk of in-stent thrombosis and 14 days for the others. Since ticlopidine effects may take 3-5 days to significantly abate, an extra week’s delay is probably warranted. Aspirin has similar pharmacodynamics, so both should be withheld for a week after the full course of antiplatelet therapy is completed. Aspirin should be resumed 48-72 hours after surgery is completed.
Plain old balloon angioplasty (POBA), by contrast, has been shown to reduce perioperative cardiac risks no matter when following POBA, the surgery is done. Clearly, the risk of acute thrombosis is less than with stents, so ticlopidine is not routinely used. Thus, for the patient who needs urgent surgery, POBA may be an acceptable alternative in appropriate cases.
After coronary stenting, elective noncardiac surgery:
a. can be performed any time.
b. should be delayed six months.
c. should be delayed 2-4 weeks.
d. should be done on aspirin and ticlopidine.
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