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.
Highlights
The development of balloon angioplasty by cardiologists was followed by the introduction of bare metal stents (BMS) to relieve obstructions in the coronary arteries
For patients requiring surgery in the first 3 - 6 months following implantation of a 1st generation drug-eluting stents (DES), the horns of the dilemma were between the risk of bleeding from, continued clopidogrel and aspirin treatment and the risk of in-stent thrombosis and myocardial infarction following discontinuation of dual antiplatelet therapy, clopidogrel and aspirin [3,4]
The evolution of stent insertion following coronary angioplasty has been complex with four different types of stent deployed in the coronary circulation after the procedure
Summary
The development of balloon angioplasty by cardiologists was followed by the introduction of bare metal stents (BMS) to relieve obstructions in the coronary arteries. For patients requiring surgery in the first 3 - 6 months following implantation of a 1st generation DES, the horns of the dilemma were between the risk of bleeding from, continued clopidogrel and aspirin treatment and the risk of in-stent thrombosis and myocardial infarction following discontinuation of dual antiplatelet therapy, clopidogrel and aspirin [3,4]. Following the demonstration of improved outcomes from coronary artery stenting at the time of balloon angioplasty intimal hyperplasia contributed to a measureable incidence of re-stenosis [22]. The drugs used were sirolimus and paclitaxel, which were incorporated into the covering of the metal in the stent and designed to be slowly washed out or eluted from the covering layer [25,26] These were the drug-eluting stents (DES), which rapidly became very popular with interventional cardiologists [24,27]. The DES had reduced the incidence of intimal hyperplasia and restenosis so for cardiologists all problems seemed to be solved [24,28,29]
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