Health  Vol.5 No.10 , October 2013
Coronary artery stents and surgery; the basis of sound perioperative management
ABSTRACT
The introduction of drug-eluting stents (DES) to interventional cardiology heralded a limited time of increased anaesthetic and surgical complications in patients implanted with these devices. The horns of the dilemma, in the anaesthetic and surgical management of patients in the first 3-6 months after the 1st generation DES insertion, were between the risk of bleeding from continued clopidogrel treatment and the risk of instent thrombosis and myocardial infarction following discontinuation of dual antiplatelet therapy, clopidogrel and aspirin. Initial accounts of early catastrophic cardiac and haemorrhagic complications, at the time of elective or emergency surgery, following DES insertion, were followed by equally worrying reports of instent thrombosis many months after DES insertion. Initial recommendations for the conduct of safe operations were propagated in the literature before formal guidelines were produced. This article summarises the issues identified in the development of interventional cardiology particularly DES and the requirement for ongoing antiplatelet therapy. The article reviews the treatment protocols that are still applicable for the different devices that have been deployed in clinical practice.

Cite this paper
Bolsin, S. , Hiew, C. , Birdsey, G. , Colson, M. and Gillet, J. (2013) Coronary artery stents and surgery; the basis of sound perioperative management. Health, 5, 1730-1736. doi: 10.4236/health.2013.510233.
References
[1]   Wilson, S.H., Fasseas, P., Oxford, J.L., Lennon, R.J., Horlocker, T., Charnoff, N.E., Melby, S. and Berger, P.B. (2003) Clinical outcomes of patients undergoing non-cardiac surgery in the two months following coronary stenting. Journal of the American College of Cardiology, 42, 234-240.
http://dx.doi.org/10.1016/S0735-1097(03)00622-3

[2]   Eisenberg, M.J. (2004) Drug-eluting stents: Some bare facts. Lancet, 364, 1466-1467.
http://dx.doi.org/10.1016/S0140-6736(04)17287-5

[3]   Spahn, D.R., Howell, S.J., Delabays, A. and Chassot, P.-G. (2006) Coronary stents and perioperative anti-platelet regimen: Dilemma of bleeding and stent thrombosis. British Journal of Anaesthesia, 96, 675-677.
http://dx.doi.org/10.1093/bja/ael098

[4]   Tsimikas, S. (2006) Drug-eluting stents and late adverse clinical outcomes lessons learned, lessons awaited. Journal of the American College of Cardiology, 47, 2112-2115.
http://dx.doi.org/10.1016/j.jacc.2006.03.019

[5]   Lee, C.H., Lim, J., Low, A., Tan, H.C. and Lim, Y.T. (2006) Late angiographic stent thrombosis of polymer based paclitaxel eluting stent. Heart, 92, 551-553.
http://dx.doi.org/10.1136/hrt.2005.073619

[6]   Nasser, M., Kapelovich, M. and Markiewicz, W. (2005) Late thrombosis of sirolumus-eluting stents following noncardiac surgery. Catheterization and Cardiovascular Interventions, 65, 516-519.
http://dx.doi.org/10.1002/ccd.20391

[7]   McFadden, E.P., Stabile, E., Regar, E., Cheneau, E., Ong, A.T.L., Kinnaird, T., Suddath, W.O., Weissman, N.J., Torguson, R., Kent, K.M., et al. (2004) Late thrombosis in drug-eluting coronary stents after discontinuation of antiplatelet therapy. Lancet, 364, 1519-1521.
http://dx.doi.org/10.1016/S0140-6736(04)17275-9

[8]   Serruys, P.W. and Daemen, J. (2007) Late stent thrombosis: A nuisance in both bare metal and drug-eluting stents. Circulation, 115, 1433-1439.
http://dx.doi.org/10.1161/CIRCULATIONAHA.106.666826

[9]   Daemen, J., Wenaweser, P., Tsuchida, K., Abrecht, L., Vaina, S., Morger, C., Kukreja, N., Juni, P., Sianos, G., Hellige, G., et al. (2007) Early and late coronary stent thrombosis of sirolimus-eluting and paclitaxel-eluting stents in routine clinical practice: Data from a large two-institutional cohort study. Lancet, 369, 667-678.
http://dx.doi.org/10.1016/S0140-6736(07)60314-6

[10]   Urban, P. and De Benedetti, E. (2007) Thrombosis: The last frontier of coronary stenting? Lancet, 369, 619-621.
http://dx.doi.org/10.1016/S0140-6736(07)60289-X

[11]   Ong, A.T., McFadden, E.P., Regar, E., de Jaegere, P.P., van Domburg, R.T. and Serruys, P.W. (2005) Late angiographic stent thrombosis (LAST) events with drug-eluting stents. Journal of the American College of Cardiology, 45, 2088-2092.
http://dx.doi.org/10.1016/j.jacc.2005.02.086

[12]   Joner, M., Finn, A.V., Farb, A., Mont, E.K., Kolodgie, F.D., Ladich, E., Kutys, R., Skorija, K., Gold, H.K. and Virmani, R. (2006) Pathology of drug-eluting stents in humans: Delayed healing and late thrombotic risk. Journal of the American College of Cardiology, 48, 193-202.
http://dx.doi.org/10.1016/j.jacc.2006.03.042

[13]   Virmani, R., Guagliumi, G., Farb, A., Musumeci, G., Grieco, N., Motta, T., Mihalcsik, L., Tespili, M., Valsecchi, O. and Kolodgie, F.D. (2004) Localized hypersensitivity and late coronary thrombosis secondary to a sirolimus-eluting stent. Circulation, 109, 701-705.
http://dx.doi.org/10.1161/01.CIR.0000116202.41966.D4

[14]   Sharma, A.K., Ajani, A.E., Hamwi, S.M., Maniar, P., Lakhani, S.V., Waksman, R. and Lindsay, J. (2004) Major noncardiac surgery following coronary stenting: When is it safe to operate? Catheterization and Cardiovascular Interventions, 63, 141-145.
http://dx.doi.org/10.1002/ccd.20124

[15]   Australia & New Zealand Cardiac Society, Guidelines Committee (2010) Guidelines for the management of antiplatelet therapy in patients with coronary stents undergoing non-cardiac surgery. Heart, Lung & Circulation, 19, 2-10. http://dx.doi.org/10.1016/j.hlc.2009.10.008

[16]   Howard-Alpe, G.M., de Bono, J., Hudsmith, L., Orr, W.P., Foex, P. and Sear, J.W. (2007) Coronary artery stents and non-cardiac surgery. British Journal of Anaesthesia, 98, 560-574. http://dx.doi.org/10.1093/bja/aem089

[17]   Harper, R.W. (2007) Drug-eluting coronary stents—A note of caution. Medical Journal of Australia, 186, 253-255.

[18]   Dupuis, J.-Y. and Labinaz, M. (2005) Noncardiac surgery in patients with coronary artery stent: What should the anesthesiologist know? Canadian Journal of Anesthesia, 52, 356-361. http://dx.doi.org/10.1007/BF03016276

[19]   Patterson, L., Hunter, D. and Mann, A. (2005) Appropriate waiting time for noncardiac surgery following coronary stent insertion: Views of Canadian anesthesiologists. Canadian Journal of Anesthesia, 52, 440-441.
http://dx.doi.org/10.1007/BF03016295

[20]   Iakovou, I., Schmidt, T., Bonizzoni, E., Ge, L., Sangiorgi, G.M., Stankovic, G., Airoldi, F., Cheiffo, A., Montorfarno, M., Carlino, M., et al. (2005) Incidence, predictors, and outcome of thrombosis after successful implantation of drugeluting stents. JAMA, 293, 2126-2130.
http://dx.doi.org/10.1001/jama.293.17.2126

[21]   Brilakis, E.S., Banerjee, S. and Berger, P.B. (2007) Perioperative management of patients with coronary stents. Journal of the American College of Cardiology, 49, 2145-2150.
http://dx.doi.org/10.1016/j.jacc.2007.02.046

[22]   Fox, K.A., Mehta, S.R., Peters, R., Zhao, F., Lakkis, N., Gersh, B.J. and Yusuf, S. (2004) Benefits and risks of the combination of clopidogrel and aspirin in patients undergoing surgical revascularization for non-ST-elevation acute coronary syndrome: The Clopidogrel in Unstable angina to prevent Recurrent ischemic Events (CURE) Trial. Circulation, 110, 1202-1208.
http://dx.doi.org/10.1161/01.CIR.0000140675.85342.1B

[23]   Kotani, J., Awata, M., Nanto, S., Uematsu, M., Oshima, F., Minamiguchi, H., Mintz, G.S. and Nagata, S. (2006) Incomplete neointimal coverage of sirolimus-eluting stents: Angioscopic findings. Journal of the American College of Cardiology, 47, 2108-2111.
http://dx.doi.org/10.1016/j.jacc.2005.11.092

[24]   Spaulding, C., Henry, P., Teiger, E., Beatt, K., Bramucci, E., Carrie, D., Slama, M.S., Merkely, B., Erglis, A., Margheri, M., et al. (2006) Sirolimus-eluting versus uncoated stents in acute myocardial Infarction. The New England Journal of Medicine, 355, 1093-1104.
http://dx.doi.org/10.1056/NEJMoa062006

[25]   Wessely, R., Schomig, A. and Kastrati, A. (2006) Sirolimus and Paclitaxel on polymer-based drug-eluting stents: Similar but different. Journal of the American College of Cardiology, 47, 708-714.
http://dx.doi.org/10.1016/j.jacc.2005.09.047

[26]   Kuchulakanti, P.K., Chu, W.W., Torguson, R., Ohlmann, P., Rha, S.W., Clavijo, L.C., Kim, S.W., Bui, A., Gevorkian, N., Xue, Z., et al. (2006) Correlates and long-term outcomes of angiographically proven stent thrombosis with sirolimusand paclitaxel-eluting stents. Circulation, 113, 1108-1113.
http://dx.doi.org/10.1161/CIRCULATIONAHA.105.600155

[27]   Daemen, J., Garcia-Garcia, H.M., Kukreja, N., Imani, F., de Jaegere, P.P., Sianos, G., van Domburg, R.T. and Serruys, P.W. (2007) The long-term value of sirolimus-and paclitaxel-eluting stents over bare metal stents in patients with diabetes mellitus. European Heart Journal, 28, 26-32. http://dx.doi.org/10.1093/eurheartj/ehl412

[28]   Gershlick, A.H. (2005) Is there any place for oral antirestenotic treatment in the era of drug eluting stents? Heart, 91, 1377-1379.
http://dx.doi.org/10.1136/hrt.2005.060954

[29]   Camenzind, E. (2006) Treatment of in-stent restenosis—Back to the future? The New England Journal of Medicine, 355, 2149-2151.
http://dx.doi.org/10.1056/NEJMe068215

[30]   Karthikeyan, G. and Bhargava, B. (2004) Prevention of restenosis after coronary angioplasty. Current Opinion in Cardiology, 19, 500-509.
http://dx.doi.org/10.1097/01.hco.0000133658.77024.59

[31]   Heeschen, C., Hamm, C.W., Goldmann, B., Deu, A., Langenbrink, L. and White, H.D. (1999) Troponin concentrations for stratification of patients with acute coronary syndromes in relation to therapeutic efficacy of tirofiban. Lancet, 354, 1757-1762.
http://dx.doi.org/10.1016/S0140-6736(99)10285-X

[32]   Zidar, J.P. (1998) Low-molecular heparins in coronary stenting (the Entices trial). ENoxaparin and TIClodipine after Elective Stenting. American Journal of Cardiology, 82, 29L-32L.
http://dx.doi.org/10.1016/S0002-9149(98)00110-6

[33]   Investigators, T.P.-P. (1998) Inhibition of the platelet glycoprotein IIb/IIIa teceptor with tirofiban in unstable angina and non-Q-wave myocardial infarction. The New England Journal of Medicine, 338, 1488-1497.
http://dx.doi.org/10.1056/NEJM199805213382102

[34]   Kristensen, S.D., Wurtz, M., Grove, E.L., De Caterina, R., Hubert, K., Moliterno, D.J. and Neumann, F.-J. (2012) Contemporary use of glycoprotein IIb/IIIa inhibitors. Thrombosis and Haemostasis, 107, 215-224.
http://dx.doi.org/10.1160/TH11-07-0468

[35]   Chassot, P.-G., Delabays, A. and Spahn, D.R. (2007) Perioperative antiplatelet therapy: The case for continuing therapy in patients at risk of myocardial infarction. British Journal of Anaesthesia, 99, 316-328.
http://dx.doi.org/10.1093/bja/aem209

[36]   Nuttall, G.A., Brown, M.J., Stombaugh, J.W., Michon, P.B., Hathaway, M.F., Lindeen, K.C., Hanson, A.C., Schroeder, D.R., Oliver, W.C., Holmes, D.R., et al. (2008) Time and cardiac risk of surgery after bare-metal stent percutaneous coronary intervention. Anesthesiology, 109, 588-595 http://dx.doi.org/10.1097/ALN.0b013e318186ddf8

[37]   Bolsin, S.N., Broad, L., Conroy, M., Black, S., Orford, N. and Birdsey, G. (2007) Successful management of patients with a drug-eluting coronary stent presenting for elective surgery. British Journal of Anaesthesia, 98, 841-842. http://dx.doi.org/10.1093/bja/aem110

[38]   Raber, L., Magro, M., Stefanini, G.G., Kalesan, B., Domburg, van R.T., Onuma, Y., Wenaweser, P., Daemen, J., Meier, B., Juni, P., et al. (2012) Very late coronary stent thrombosis of a newer-generation everolimus-eluting stent compared with early-generation drug-eluting stents: A prospective cohort study. Circulation, 125, 1110-1121.
http://dx.doi.org/10.1161/CIRCULATIONAHA.111.058560

[39]   Stefanini, G.G., Byrne, R.A., Serruys, P.W., Waha, de A., Meier, B., Massberg, S., Jani, P., Schamig, A., Windecker, S. and Kastrati, A. (2012) Biodegradable polymer drugeluting stents reduce the risk of stent thrombosis at 4 years in patients undergoing percutaneous coronary intervention: A pooled analysis of individual patient data from the ISAR-TEST 3, ISAR-TEST 4, and LEADERS randomized trials. European Heart Journal, 33, 1214-1222.
http://dx.doi.org/10.1093/eurheartj/ehs086

[40]   Dalal, A.R., D’Souza, S. and Shulman, M. (2006) Brief review: Coronary drug-eluting stents and anesthesia. Canadian Journal of Anesthesia, 53, 1230-1243.
http://dx.doi.org/10.1007/BF03021585

[41]   Shuchman, M. (2007) Debating the risks of drug-eluting stents. The New England Journal of Medicine, 356, 325-328. http://dx.doi.org/10.1056/NEJMp068300

[42]   Kaluza, G.L., Joseph, J., Lee, J.R., Raizner, M.E. and Raizner, A.E. (2000) Catastrophic outcomes of noncardiac surgery soon after coronary stenting. Journal of the American College of Cardiology, 35, 1288-1294.
http://dx.doi.org/10.1016/S0735-1097(00)00521-0

[43]   Vicenzi, M.N., Meislitzer, T., Heitzinger, B., Halaj, M., Fleisher, L.A. and Metzler, H. (2006) Coronary artery stenting and non-cardiac surgery—A prospective outcome study. British Journal of Anaesthesia, 96, 686-693.
http://dx.doi.org/10.1093/bja/ael083

[44]   Liistro, F. and Colombo, A. (2001) Late acute thrombosis after paclitaxel eluting stent implantation. Heart, 86, 262-264. http://dx.doi.org/10.1136/heart.86.3.262

[45]   Spaulding, C., Daemen, J., Boersma, E., Cutlip, D.E. and Serruys, P.W. (2007) A pooled analysis of data comparing sirolimus-eluting stents with bare-metal stents. The New England Journal of Medicine, 356, 989-997.
http://dx.doi.org/10.1056/NEJMoa066633

[46]   Conroy, M., Bolsin, S.N., Black, S.A. and Orford, N. (2007) Perioperative complications in patients with drugeluting stents: A three-year audit at Geelong Hospital. Anaesthesia and Intensive Care, 35, 939-944.

[47]   Broad, L., Lee, T., Conroy, M., Bolsin, S., Orford, N., Black, A. and Birdsey, G. (2007) Successful management of patients with a drug-eluting coronary stent presenting for elective, non-cardiac surgery. British Journal of Anaesthesia, 98, 19-22. http://dx.doi.org/10.1093/bja/ael318

[48]   Barthwal, R. and Herman, B.A. (2008) Very late stent thrombosis after discontinuation of clopidogrel therapy. Medical Journal of Australia, 189, 229-230.

[49]   Godet, G., Le Manach, Y., Lesache, F., Perbet, S. and Coriat, P. (2008) Drug-eluting stent thrombosis in patients undergoing non-cardiac surgery: Is it always a problem? British Journal of Anaesthesia, 100, 472-477.
http://dx.doi.org/10.1093/bja/aen033

[50]   Barash, P. and Akhtar, S. (2010) Coronary stents: Factors contributing to perioperative major adverse cardiovascular events. British Journal of Anaesthesia, 105, i3-i15.
http://dx.doi.org/10.1093/bja/aeq318

[51]   Park, D.W., Park, S.W., Park, K.H., Lee, B.K., Kim, Y.H., Lee, C.W., Hong, M.K., Kim, J.J. and Park, S.J. (2006) Frequency of and risk factors for stent thrombosis after drug-eluting stent implantation during long-term follow-up. American Journal of Cardiology, 98, 352-356.
http://dx.doi.org/10.1016/j.amjcard.2006.02.039

[52]   Taylor-Sutton, J.E. (2011) Very late stent thrombosis approximately 7 years after deployment and one week cessation of dual antiplatelet therapy. Journal of Invasive Cardiology, 23, E273-E276.

[53]   Savonitto, S., D’Urbano, M., Caracciolo, M., Barlocco, F., Mariani, G., Nichelatti, M., Klugmann, S. and De Servi, S. (2010) Urgent surgery in patients with a recently implanted coronary drug-eluting stent: A phase II study of “bridging” antiplatelet therapy with tirofiban during temporary withdrawal of clopidogrel. British Journal of Anaesthesia, 104, 285-291. http://dx.doi.org/10.1093/bja/aep373

[54]   Marcos, E.G., Da Fonseca, A.C. and Hofma, S.H. (2011) Bridging therapy for early surgery in patients on dual antiplatelet therapy after drug-eluting stent implantation. Netherlands Heart Journal, 19, 412-417.
http://dx.doi.org/10.1007/s12471-011-0197-y

[55]   Weber, A.A., Braun, M., Hohfeld, T., Schwippert, B., Tschope, D. and Schror, K. (2001) Recovery of platelet function after discontinuation of clopidogrel treatment in healthy volunteers. British Journal of Clinical Pharmacology, 52, 333-336.
http://dx.doi.org/10.1046/j.0306-5251.2001.01453.x

[56]   Duckers, H.J., Silber, S., Winter, de R., Heijer, den P., Rensing, B., Rau, M., Mudra, H., Benit, E., Verheye, S., Wijns, W., et al. (2007) Circulating endothelial progenitor cells predict angiographic and intravascular ultrasound outcome following percutaneous coronary interventions in the HEALING-II trial: Evaluation of an endothelial progenitor cell capturing stent. EuroIntervention, 3, 67-75.
http://dx.doi.org/10.4244/EIJV3I3A64

[57]   Aoki, J., Serruys, P.W., Beusekom, van H., Ong, A.T.L., McFadden, E.P., Sianos, G., Giessen, van der W.J., Regar, E., Feyter, de P.J., Davis, H.R., et al. (2005) Endothelial progenitor cell capture by stents coated with antibody against CD34: The HEALING-FIM (Healthy Endothelial Accelerated Lining Inhibits Neointimal Growth-First in Man) Registry. Journal of the American College of Cardiology, 45, 1574-1579.
http://dx.doi.org/10.1016/j.jacc.2005.01.048

[58]   Duckers, H.J., Soullié, T., Heijer, den P., Rensing, B., Winter, de R.J., Rau, M., Mudra, H., Silber, S., Benit, E., Verheye, S., et al. (2007) Accelerated vascular repair following percutaneous coronary intervention by capture of endothelial progenitor cells promotes regression of neointimal growth at long term follow-up: Final results of the Healing II trial using an endothelial progenitor cell capturing stent (Genous R stent). EuroIntervention, 3, 350-358. http://dx.doi.org/10.4244/EIJV3I3A64

[59]   Sangiorgi, G., Morice, M.-C., Bramucci, E., Ferlini, M., Grinfeld, L., Petronio, A.S., Pierli, C., Iadanza, A., Biondi-Zoccai, G. and Colombo, A. (2011) Evaluating the safety of very short-term (10 days) dual antiplatelet therapy after Genous bio-engineered R stent implantation: The multicentre pilot GENOUS trial. EuroIntervention, 7, 813-819. http://dx.doi.org/10.4244/EIJV7I7A128

[60]   Grines, C.L., Bonow, R.O., Casey, D.E., Gardner, T.J., Lockhart, P.B., Moliterno, D.J., O’Gara, P. and Whitlow, P. (2007) Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: A science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation, 115, 813-818.
http://dx.doi.org/10.1161/CIRCULATIONAHA.106.180944

[61]   Collet, J.P., Montalescot, G., Blanchet, B., Tanguy, M.L., Golmard, J.L., Choussat, R., Beygui, F., Payot, L., Vignolles, N., Metzger, J.P., et al. (2004) Impact of prior use or recent withdrawal of oral antiplatelet agents on acute coronary syndromes. Circulation, 110, 2361-2367.
http://dx.doi.org/10.1161/01.CIR.0000145171.89690.B4

[62]   Ferrari, E., Benhamou, M., Cerboni, P. and Marcel, B. (2005) Coronary syndromes following aspirin withdrawal. Journal of the American College of Cardiology, 45, 456-459. http://dx.doi.org/10.1016/j.jacc.2004.11.041

[63]   Levine, G.N., Bates, E.R., Blankenship, J.C., Bailey, S.R., Bittl, J.A., Cercek, B., Chambers, C.E., Ellis, S.G., Guyton, R.A., Hollenberg, S.M., et al. (2011) ACCF/AHA/ SCAI guideline for percutaneous coronary intervention: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation, 124, e574-e651.
http://dx.doi.org/10.1161/CIR.0b013e31823ba622

[64]   Ferreira-Gonzalez, I., Marsal, J.R., Ribera, A., Permanyer-Miralda, G., Garcia-Del, Blanco B., Marta, G., Cascant, P., Masotti-Centol, M., Carrillo, X., Mauri, J., et al. (2012) Double antiplatelet therapy after drug-eluting stent implantation: Risk associated with discontinuation within the first year. Journal of the American College of Cardiology, 60, 1333-1339.
http://dx.doi.org/10.1016/j.jacc.2012.04.057

[65]   Kim, B.-K., Hong, M.-K., Shin, D.-H., Nam, C.-M., Kim, J.-S., Ko, Y.-G., Choi, D., Kang, T.-S., Park, B.-E., Kang, W.-C., et al. (2012) A new strategy for discontinuation of dual antiplatelet therapy: The RESET Trial (REal Safety and Efficacy of 3-month dual antiplatelet Therapy following Endeavor zotarolimus-eluting stent implantation). Journal of the American College of Cardiology, 60, 1340-1348. http://dx.doi.org/10.1016/j.jacc.2012.06.043

 
 
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