Der Patient mit Koronarstent

Nowadays stents are implanted in over 90% of percutaneous coronary interventions. Depending on the type of stent implanted, dual antiplatelet therapy combining a cyclooxygenase inhibitor such as acetylsalicylic acid and an adenosine diphosphate receptor antagonist (thienopyridine) such as clopidogrel is required for 1–12 months. Premature termination of antiplatelet therapy during non-cardiac surgery significantly increases the risk of stent thrombosis and consequently myocardial infarction, whereas continuation of dual antiplatelet therapy during surgery increases the risk of severe bleeding. Accordingly, treatment recommendations have to be based on the individual relative risk. In cases with a high risk for major bleeding during surgery, interruption of antiplatelet therapy may be required, whereas in cases of a high risk of stent thrombosis, both antiplatelet drugs should be continued throughout surgery. Patients on dual antiplatelet therapy should be counseled by a team of anesthesiologists, surgeons and cardiologists, to devise the right point in time for the operation, the best perioperative antiplatelet therapy and the appropriate perioperative monitoring.     

Intraoperative drug-eluting stent thrombosis in a patient undergoing robotic prostatectomy

Insertion of drug-eluting stents is one of the strategies for treating patients with coronary artery disease. These patients can be a perioperative challenge in management as they need to be maintained on antiplatelet therapy to prevent stent thrombosis, which puts them at an increased risk for surgical bleeding. Recently revised guidelines on elective surgery following insertion of a drug-eluting stent recommend dual antiplatelet therapy for a period of twelve months. The management of a patient who presented for surgery more than two years after the insertion of a drug-eluting stent, and who developed in-stent thrombosis intraoperatively, is presented.     

Antiplatelet therapy and coronary stents in perioperative medicine--the two sides of the coin

New trends in interventional cardiology, e.g. the increasing practice of coronary intervention with stent implantation and the prolonged use of dual antiplatelet therapy--usually a combination of clopidogrel and aspirin--has also increased the number of patients presenting for non-cardiac surgery. The two most commonly used stent types, bare-metal stents (BMSs) and drug-eluting stents (DESs), mandate different lengths of dual antiplatelet drug therapy to avoid stent thrombosis. Perioperative caregivers face a knife-edge dilemma between perioperative stent thrombosis, due to preoperative discontinuation of antiplatelet drugs, or surgical bleeding, by continuation of therapy. Pre- and intraoperatively, the risk factors for thrombosis have to be balanced against the risk factors for surgical bleeding. As long as prospective trials are not available, the recommendations and guidelines of task forces and experts are based on retrospective studies and case reports. The perioperative management, decision trees and the importance of close interdisciplinary collaboration between cardiologists, surgeons and anaesthetists will be described.     

Perioperatives Management von Patienten mit Koronarstents bei nichtherzchirurgischen Eingriffen

In patients with coronary stents scheduled for surgery the question arises whether and how antiplatelet therapy should be continued. Risks of perioperative bleeding and of acute stent thrombosis have to be considered simultaneously. The bleeding risk depends primarily on the kind of surgery and on patient comorbidity. The risk of stent thrombosis is increased in these patients due to the thrombogenic surface of the stents. The main determinants are hereby the time duration after stent implantation, the kind of the stent [uncoated (bare-metal stent, BMS) or coated (drug-eluting stent, DES)], as well as angiographic and clinical patient factors. Therefore, perioperative antiplatelet therapy has to be individually adapted for each patient. Bridging with heparin is ineffective. Bridging with intravenous antiplatelet drugs during the perioperative interruption of oral antiplatelet therapy might be a potential procedure in high-risk patients. Whether bedside monitoring of antiplatelet therapy improves the perioperative management of these patients and reduces adverse outcome is object of current studies.     

Platelet function: new drugs, new assays : possible impacts on operative medicine?

Dual antiplatelet therapy with aspirin and a P2Y12 receptor blocker is a well-established strategy to prevent thrombotic complications in patients with acute coronary syndromes (ACS) and after percutaneous coronary interventions (PCI). Current practice guidelines for antiplatelet therapy advocate a 1 to 12-month dual antiplatelet therapy after bare metal stent PCI and an up to 12-month dual antiplatelet therapy after PCI in patients with ACS and drug-eluting stent PCI. Premature withdrawal of dual antiplatelet therapy carries a substantial risk of stent thrombosis but perioperative continuation of dual antiplatelet therapy is associated with an increased risk of bleeding, particularly in patients treated with the new potent drugs prasugrel and ticagrelor. Based on the various available assays, the lack of validated cut-offs and the disappointing results of targeted antiplatelet therapy as demonstrated by the GRAVITAS trial, current guidelines of international societies recommend platelet function testing only for selected high risk patients despite the known association between clopidogrel low responsiveness and ischemic events. However, for individual patients taking clopidogrel, platelet function monitoring may be considered to safely shorten the preoperative waiting period, to assess the risk of bleeding and transfusion and to initiate specific therapy in bleeding patients.     

Thrombozytenfunktionshemmung nach koronarer Stentimplantation: Bedeutung in der Endoprothetik

Coronary stenting is an effective treatment for reopening atherosclerotic occlusions of coronary arteries. Depending on the manifestation of coronary artery disease (stable CAD or acute coronary syndrome) and on the type of implanted stent, dual antiplatelet therapy is recommended for a period of 4 weeks to 12 months. In this period total joint replacement is associated with high blood loss and high perioperative morbidity. Therefore antiplatelet therapy is often discontinued and replaced by higher dosages of heparin for prophylactic anticoagulation. However, with this treatment regimen protection of the stent is doubtful and there is a high risk of stent thrombosis with myocardial infarction. The surgery should be scheduled after the dual antiplatelet therapy is replaced by lifelong aspirin therapy. On the other hand, if surgery cannot be postponed perioperative bridging of dual antiplatelet therapy can be conducted to minimize bleeding complications with the best possible stent protection. Lifelong therapy with aspirin should not be discontinued in any case.     

Perioperatives Pausieren der antithrombozytären Therapie bei Patienten mit koronaren Stents

According to the present guidelines, patients with coronary stents are to be treated with dual antiplatelet therapy. In case surgery is needed, the risk of a fatal stent thrombosis by withdrawing antithrombotics needs to be balanced in each individual case against the risk of haemorrhagic complications on continued antiplatelet medication. We present a case of fatal stent thrombosis and discuss the current evidence regarding perioperative continuation and interruption of antiplatelet therapy for this patient population. In summary the haemorrhagic risk with acetylsalicylic acid for secondary prevention seems very low, and it should be discontinued only in selected cases. Continued dual anticoagulation concepts are also discussed.     

Perioperative management of patients with drug-eluting coronary stents presenting for non-cardiac surgery

After the approval of the drug-eluting coronary stent in Japan in 2004, Japanese cardiologists took the benefit of this new technology to improve the post percutaneus coronary intervention complication of restenosis. Post market studies of drug-eluting coronary stent are becoming available. Unfortunately, many of the results indicate the risk of late stent thrombosis. The chance of stent thrombosis seems elevated when a patient is without antiplatelet medication, dehydrated and in a stressed state. Operation puts the patient in such adverse conditions that might render him to thrombo-producting state. As the use of drug-eluting stent becomes popular, the management of those patients in operative settings becomes inevitable. In this paper, we reviewed the medical records of 20 patients for surgery with drug-eluting coronary stents in our hospital. Time intervals between stent placement and surgery were: less than 90 days (2 cases), less than 180 days (3 cases), less than one year (8 cases), more than one year (7 cases). There was no stent thrombosis in the perioperative period. We did not take precautionary steps for stent thrombosis in the perioperative period, except in two cases where operations were performed recently (One patients received heparin and the other patients received aspirin and cilostazol). None of patients had excessive blood loss. However, many reports suggest the increasing risk of stent thrombosis in patients with the drug-eluting coronary stents presenting for non-cardiac surgery. They also suggest that, in contrast to bare metal stent, there may be no association between the risk of stent thrombosis and time intervals from stent placement to surgery. We should pay more attention to management of patients with drug-eluting coronary stents presenting for non-cardiac surgery.     

Coronary stents: factors contributing to perioperative major adverse cardiovascular events

Patients with coronary stents undergoing non-cardiac surgery are at increased risk of major adverse cardiovascular events perioperatively. Impeccable patient care and communication between all members of the healthcare team will minimize this risk. The dominant risk factor for stent thrombosis and major adverse cardiovascular events is the interruption of dual antiplatelet therapy (e.g. aspirin and clopidogrel). If clopidogrel therapy has to be interrupted due to increased risk of bleeding, continuation of aspirin is strongly recommended to reduce the risk of stent thrombosis. The interval between percutaneous coronary interventions and operation is the next major risk factor for stent thrombosis. The incidence of major adverse cardiovascular events is inversely related to this interval, with the highest mortality rate occurring <30 days after stent implantation. Ideally, for patients with drug-eluting stents, elective surgery should be delayed for at least 1 yr and for patients with bare-metal stents, the recommended minimum period is 6 weeks. The use of a neuraxial anaesthetic technique must be carefully considered due to the risk of an epidural haematoma. Perioperative monitoring should focus on early recognition of myocardial ischaemia, infarction, or both. If stent thrombosis is present, rapid triage to an interventional catheterization laboratory is essential for restoration of coronary blood flow.     

The Management of Patients on Dual Antiplatelet Therapy Undergoing Orthopedic Surgery

Cardiovascular disease is prevalent in patients undergoing orthopedic surgery. Many patients who have undergone previous percutaneous coronary intervention (PCI) with stenting are on dual antiplatelet therapy in order to minimize the risk of stent thrombosis. The optimal management of these patients in the perioperative setting remains unclear. We aim to provide information about the management of patients who have undergone a PCI with stents who are subsequently indicated for an orthopedic procedure. We will review the concerns from a cardiologist's and orthopedic surgeon's perspective in regards to the management of these patients in the perioperative setting. In addition, the current American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, and American College of Surgeons guidelines are reviewed. The decision to discontinue dual antiplatelet therapy in a patient who has undergone a PCI with stent should be made only after careful review of the risks for thrombosis and bleeding. Best practice suggests that these risks should be jointly assessed by the orthopedic surgeon and cardiologist. Those patients with stents at high risk of thrombosis should have surgery delayed if possible. There is little data supporting a significantly increased bleeding risk associated with mortality in orthopedic patients when antiplatelet therapy is continued perioperatively.     

Coronary stents, dual antiplatelet therapy and peri-operative problems

Up to 90% of all percutaneous coronary interventions include coronary artery stenting. Dual antiplatelet therapy, usually involving acetylsalicyl acid combined with clopidogrel, is mandatory for patients with coronary artery stents. The duration of antiplatelet therapy for bare metal stents is 3-4 weeks, for drug eluting stents 6-12 months. Preoperative discontinuation of both drugs increases the risk of stent thrombosis, continuation the risk of relevant bleeding. According to the recommendations of anaesthesiological and cardiological societies, perioperative management has to balance the risk of bleeding vs stent thrombosis. Surgery involving a high risk of bleeding can require the discontinuance of both substances. In cases of high thrombosis risk, at least the acetylsalicyl acid should be continued until the day of surgery. For patients under antiplatelet therapy scheduled for local anaesthesia, national recommendations exist. A close collaboration between the anaesthesiologist, cardiologist and surgeon is essential for appropriate pre-, intra- and postoperative management.     

Koronare Stents, duale Antiplättchentherapie und die perioperative Problematik

Up to 90% of all percutaneous coronary interventions include coronary artery stenting. Dual antiplatelet therapy, usually involving acetylsalicyl acid combined with clopidogrel, is mandatory for patients with coronary artery stents. The duration of antiplatelet therapy for bare metal stents is 3–4 weeks, for drug eluting stents 6–12 months. Preoperative discontinuation of both drugs increases the risk of stent thrombosis, continuation the risk of relevant bleeding. According to the recommendations of anaesthesiological and cardiological societies, perioperative management has to balance the risk of bleeding vs stent thrombosis. Surgery involving a high risk of bleeding can require the discontinuance of both substances. In cases of high thrombosis risk, at least the acetylsalicyl acid should be continued until the day of surgery. For patients under antiplatelet therapy scheduled for local anaesthesia, national recommendations exist. A close collaboration between the anaesthesiologist, cardiologist and surgeon is essential for appropriate pre-, intra- and postoperative management.     

Perioperative management of antiplatelet agents

Perioperative management of antiplatelet agents is a common challenge with the increased number of patients requiring long-term therapy following coronary stenting. Debate currently exists regarding if and when to discontinue antiplatelet therapy prior to elective surgery. The delicate balance between decreasing the risk of bleeding intraoperatively and minimizing the risk of stent thrombosis in patients who are already at a high thrombotic risk is a major concern. This article summarizes the information available for perioperative management of common antiplatelet agents, as well as antiplatelet agents in development.     

Coronary stent management in elective genitourinary surgery

What's known on the subject? and What does the study add? Withdrawal of dual antiplatelet therapy before the recommended, 12 months for drug‐eluting stents and 1 month for bare‐metal stents increases the rate of major adverse coronary events and mortality. However, in those undergoing surgery the risk of bleeding is increased substantially for those on antiplatelet agents. Successful management in patients with coronary stents who must undergo elective or non‐elective urological surgery should be a multidisciplinary decision. This article reviews the literature and recommends a protocol for clinical management of patients undergoing urological procedures after coronary stent placement. To review the literature on coronary stents and genitourinary surgery and provide a protocol for perioperative. The keywords, ‘elective surgery’, ‘aspirin’, ‘clopidogrel’, ‘guidelines for percutaneous coronary intervention’, and ‘antiplatelet therapy after coronary stent placement’ were used to search PubMed for any relevant articles relating to coronary stents. Recommendations were made based on the whether the procedures patients were exposed to placed them at low‐, moderate‐ or high‐bleeding risk based on the extent of the procedure. All elective procedures should be delayed for 1 month after bare‐metal stent placement and 1 year after drug‐eluting stent placement. In patients classified as low risk (endoscopy and laser prostatectomy), aspirin should be continued throughout the perioperative period and dual antiplatelet therapy should continue 24–48 h postoperatively, if there is no concern for active bleeding. In those classified as moderate risk (scrotal procedures, transurethral resection of bladder tumours, transurethral resection of the prostate, urinary sphincter placement) dual antiplatelet therapy should be discontinued 5–7 days before the procedure and continued within 7 days after procedure, if there is no concern for active bleeding, in consultation with cardiology. In high‐risk procedures (cystectomy, nephrectomy, prostatectomy, penile prosthesis placement) dual antiplatelet therapy should be discontinued 10 days before the procedure and continued postoperatively within 7–10 days of the procedure, when there is no longer a concern for active bleeding with the assistance of a cardiologist. Coronary artery disease is becoming more prominent in our society, increasing the use of coronary stents and antiplatelet agents. With the proposed protocol, it is safe to proceed with surgical intervention in those that have adequate stent endothelialisation.     

冠脉支架患者非心脏手术的围手术期处理

背景 近三十年来,心脏冠脉支架患者日益增多,此类患者在接受非心脏手术时其围手术期将面临特殊挑战.目的 现将重点讨论支架血栓的病理生理以及冠脉支架患者非心脏手术围手术期的处理策略.内容 冠脉支架患者为预防支架内血栓的发生,通常接受由阿司匹林和氯吡格雷为主要药物的双联抗血小板治疗,其疗程为裸金属支架bare metal s...     

经皮冠状动脉支架介入治疗患者行非心脏手术抗血小板治疗的困惑与思考

冠状动脉粥样硬化性心脏病患者日益增多,其中有相当比例的患者接受了经皮冠状动脉介入治疗及术后双联抗血小板治疗。这些患者如果短期内需要接受非心脏手术将面临失血增加的危害,但是如果停止抗血小板治疗,围手术期支架内血栓形成的风险和心肌梗死的发生率将增加。文章针对上述问题就冠状动脉支架植入患者术后抗凝治疗的主要药物、有效性及安全...     

Emergent coronary artery bypass grafting for cardiogenic shock caused by very late drug-eluting stent thrombosis

We describe a case of cardiogenic shock caused by a very late drug-eluting stent (DES) thrombosis. The patient underwent emergent coronary artery bypass grafting (CABG) and was discharged home 15 days after the operation. The incidence of stent restenosis had been reduced by the use of DES, but the Achilles’ heel of DES is represented by a higher rate of stent thrombosis. In our case, the DES thrombosis occurred 5 years after its implantation, underlining the importance of prolonged dual antiplatelet therapy. Even though rare, this complication may be life-threatening. We believe that CABG provides better event-free survival than percutaneous coronary intervention in patients with multivessel coronary disease despite the use of DES.     

Anticoagulation after coronary artery surgery in patients with polycythemia vera: report of two cases

Polycythemia vera is a myeloproliferative disorder associated with the thromboembolic events. Normalization of the hematocrit and elevated platelet counts is obligatory to reduce the thrombotic risk of patients with PV. Therapeutic strategies include phlebotomy, myelosuppressive agents, and, more recently, interferon-alpha. In addition, appropriate antiplatelet therapy should be administered to prevent life-threatening complications and reducing the viscosity of the blood. Although aspirin is widely preferred in such patients, this monodrug therapy or combined with clopidogrel as an alternative approach might not be enough, especially after coronary artery surgery. Therefore, warfarin should be added to anticoagulant therapy. This short report describes the use of warfarin, associated with aspirin and clopidogrel as an anticoagulant regimen after coronary artery bypass surgery in two cases with polycythemia vera. We believe that a combination of warfarin with other oral antiplatelet agents may be more effective in preventing the coronary artery bypass graft thrombosis.     

Late coronary stent thrombosis complicating urologic surgery

The current practice of withdrawing antiplatelet therapy before major surgery has been challenged by the introduction of coronary drug-eluting stents (DESs) since evidence is accumulating that a DES requires dual antiplatelet therapy for at least a year. The authors present a case demonstrating difficulty in decision-making when it comes to appropriate perioperative antiplatelet therapy. The patient experienced a coronary stent thrombosis possibly due to discontinuation of clopidogrel prior to urologic surgery.     

Brief review: Coronary drug-eluting stents and anesthesia

Purpose

Anesthesiologists managing patients with drug-eluting stents (DES) face the challenge of balancing the risks of bleedingvs perioperative stent thrombosis (ST). This article reviews DES and the influence of antiplatelet medications related to their use. A perioperative management algorithm is suggested. Novel P2Y12 antagonists currently under investigation, including cangrelor and prasugrel are considered, as well as their potential role in modification of perioperative cardiovascular risks and management of patients with DES.

Source

A PubMed search of the relevant literature over the period 1985–2005 was undertaken using the terms “drug-eluting stent”, “coronary artery stent”, “bare metal stent”, “antiplatelet medication”, “aspirin”, “clopidogrel.”

Principal findings

Delayed re-endothelialization may render both sirolimus-eluting and paclitaxel-eluting stents susceptible to thrombosis for a longer duration than bare metal stents. Stent thrombosis may be associated with resistance to antiplatelet medication. In patients with a DES, a preoperative cardiology consultation is essential. Elective surgery should be postponed if the duration between DES placement and noncardiac surgery is less than six months. For semi-emergent procedures, both aspirin and clopidogrel should be continued during surgery unless clearly contraindicated by the nature of the surgery. If the risk of bleeding is high, then modification of antiplatelet medications should be considered on a case-by-case basis.

Conclusion

A profound increase in the number of patients with DES requires anesthesiologists to be familiar with their associated antiplatelet medications, and strategies for risk modification of ST and possible hemorrhagic complications in the perioperative setting.