Perioperative Antiplatelet Management Research Articles

Carotid Angioplasty and Stenting for Occlusive Diseases.

Stenting for carotid artery stenosis (CAS) was once denied 15years ago because it failed to prove the non-inferiority to carotid endarterectomy (CEA). However, it is now reevaluated and is thought better due to higher safety and efficacy thanks to the development of devices, strategies, and various protection methods. To achieve the safe CAS, protection methods and stents should be properly selected based on the vessel course and plaque components on the preoperative plaque images. Particularly multiple protection methods including proximal balloon protection and double-layer micromesh stents are useful for the cases with high-risk and fragile plaque. Perioperative anti-platelet management and the control of blood pressure are also important to avoid the ischemic complications and hyperperfusion. Properly protected and tailored CAS based on the risk management has dramatically improved the clinical results and contributed to extend the indication for more difficult lesions.

Perioperative risk and antiplatelet management in patients undergoing non-cardiac surgery within 1 year of PCI.

Perioperative cardiovascular complications are important causes of morbidity and mortality associated with non-cardiac surgery, especially in patients with recent percutaneous coronary intervention (PCI). We aimed to illustrate the types and timing of different surgeries occurring after PCI, and to evaluate the risk of thrombotic and bleeding events according to the perioperative antiplatelet management. Patients undergoing urgent or elective non-cardiac surgery within 1 year of PCI at a tertiary-care center between 2011 and 2018 were included. The primary outcome was major adverse cardiac events (MACE; composite of death, myocardial infarction, or stent thrombosis) at 30 days. Perioperative bleeding was defined as ≥ 2 units of blood transfusion. A total of 1092 surgeries corresponding to 747 patients were classified by surgical risk (low: 50.9%, intermediate: 38.4%, high: 10.7%) and priority (elective: 88.5%, urgent/emergent: 11.5%). High-risk and urgent/emergent surgeries tended to occur earlier post-PCI compared to low-risk and elective ones, and were associated with an increased risk of both MACE and bleeding. Preoperative interruption of antiplatelet therapy (of any kind) occurred in 44.6% of all NCS and was more likely for procedures occurring later post-PCI and at intermediate risk. There was no significant association between interruption of antiplatelet therapy and adverse cardiac events. Among patients undergoing NCS within 1 year of PCI, perioperative ischemic and bleeding events primarily depend on the estimated surgical risk and urgency of the procedure, which are increased early after PCI. Preoperative antiplatelet interruption was not associated with an increased risk of cardiac events.

Update on the perioperative management of antiplatelets and anticoagulants in ophthalmic surgery.

Anti-thrombotic drugs (antiplatelets and anticoagulants) are widely used for different clinical reasons. This means that there are an increasing number of patients undergoing elective ophthalmic surgery that are being treated with these drugs. A better knowledge of their implications and their peri-operative use may help to prevent surgical and secondary adverse events. There is often no firm recommendation on how to manage certain drugs in certain surgeries. To review the recommendations in the scientific literature as regards managing anti-thrombotic agents during the peri-operative period of ophthalmic surgery. A review was made of the relevant guidelines and studies using an antiplatelet and anticoagulant drugs approach for cataract, vitreo-retinal, glaucoma, oculoplastic, and strabismus surgeries. Recommendations about whether to continue or discontinue anti-thrombotic drugs in the peri-operative period of different ophthalmic surgical fields are presented. There are only firm recommendations of maintaining anti-thrombotic drugs as regards cataract surgery using phacoemulsification with topical anaesthesia. In other surgical fields, ophthalmologists should balance the risk of thromboembolic events and risks of haemorrhagic complications in order to carry out a proper management. A multi-disciplinary approach is recommended for complex cases. Additional studies should be performed to better characterise the peri-operative use of anti-thrombotic agents in order to prepare clinical guidelines for ophthalmic surgery.

Effect of Perioperative Antiplatelet Management on Thromboembolic Coplications after Liver Resection

Aim: The aim of the study is to specify the effect of perioperative antiplatelet (APT) management on postoperative thromboembolism (TE) after liver resection. Methods: Consecutive 398 patients undergoing liver resection at our hospital from 2005 to 2017 were retrospectively reviewed. Our perioperative antithrombotic management protocol includes preoperative aspirin monotherapy for patients with high thromboembolic risks. Among them, 125 patients (31.4%) had atherosclerotic thromboembolic risk and received APT. The cohort was classified into three groups; patients without APT (N-APT group), APT-discontinued patients (D-APT group), and aspirin-continued patients (C-APT group), The predicted risk of each group was assessed by CHADS2 score, and the rates of TE were compared between the groups. Results: Significantly lower CHADS2 score of N-APT group was observed compared to those of other groups, although the D-APT and C-APT groups had similar distribution of the scores. Among 398 patients, postoperative TE was found in 6 cases (1.5%). Three cases resulted in in-hospital death and other 3 patients were discharged with moderate to severe sequelae. More TE occurred in the D-APT group (4.2%), whereas only one case in the C-APT group (1.9%) and three cases in the N-APT group (0.7%) were observed (p=0.038). Although having high CHADS2 scores, patients in C-APT group showed a relatively low rate of postoperative TE events, mainly due to the preventive effect of preoperative aspirin continuation against TE. Conclusion: Especially in patients with APT for thrombotic risks, it is suggested that management with continued preoperative single aspirin therapy should be considered regardless of TE risks.

Abstract 15502: Clinical Outcomes in Patients Undergoing Non-cardiac Surgery Within 1 Year of Pci

Introduction: Perioperative cardiovascular events are an important cause of morbidity and mortality associated with non-cardiac surgery (NCS), especially in patients with recent percutaneous coronary intervention (PCI) who require dual antiplatelet therapy. Objective: To illustrate the types and timing of different noncardiac surgeries occurring within 1 year of PCI, and to evaluate the risk of thrombotic and bleeding events according to perioperative antiplatelet management. Methods: All patients undergoing NCS within 1 year of PCI at a tertiary-care center between 2011 and 2018 were included. The primary outcome was major adverse cardiac events (MACE; composite of death, myocardial infarction, stent thrombosis or target vessel revascularization). The key secondary outcome was major bleeding, defined as ≥2 units of blood transfusion. All outcomes were evaluated at 30 days after NCS. Results: A total of 1092 NCS (corresponding to 747 patients) were included and classified by surgical risk (low: 50.9%, intermediate: 38.4%, high: 10.7%) and priority (elective: 88.5%, urgent/emergent: 11.5%). High-risk and urgent/emergent surgeries tended to occur earlier post-PCI compared to low-risk and elective ones ( Figure-A ). The incidence of MACE and bleeding was time-dependent, with an increased risk in surgeries occurring in the first 6 months post-PCI ( Figure-B ). Perioperative antiplatelet cessation occurred in 487 (44.6%) NCS and was more likely for intermediate-risk procedures and after 6 months of PCI. There was no significant association between antiplatelet cessation and cardiac events. Conclusions: Among patients undergoing NCS within 1 year of PCI, the perioperative risk of MACE is inversely related to time from PCI. Preoperative interruption of antiplatelet therapy was observed in less than half of all cases and was not associated with an increased risk of cardiac events.

Perioperative Bridging/Cessation of Antiplatelet Agents: 2020 Update

Perioperative management of patients receiving antiplatelet therapy is common and must carefully balance the risk of ischemia or thrombosis with bleeding. Here we describe pathways of platelet aggregation unique to the perioperative period and mechanisms of commonly encountered antiplatelet medications, and review current literature evaluating strategies for antiplatelet management surrounding elective noncardiac and cardiac surgery. Antiplatelet therapies demonstrate unique risk profiles for stent thrombosis and bleeding that may be dependent on individual genetic polymorphisms. Use of scoring systems or point-of-care platelet function assays may identify patients especially vulnerable to alterations in perioperative antiplatelet management, and guide timing of surgery. Prior guidelines, which recommend a minimum 6-month delay in elective surgery for patients receiving dual-antiplatelet therapy following percutaneous coronary intervention (PCI), may be amended to 3 months in certain cases in which newer generation antiplatelet therapies are administered. While use of intravenous bridging agents may reduce platelet reactivity during cardiac surgery, there is no single antiplatelet strategy which consistently reduces rates of major bleeding or cardiovascular events. There is insufficient evidence to support any specific perioperative antiplatelet strategy. Cases should be individualized to balance the risks of stent thrombosis and bleeding. Current recommendations may be modified if the risk of delaying surgery outweighs the risk of stent thrombosis. It is reasonable to guide management by utilizing scoring systems and point-of-care platelet function assays.

Safety and Feasibility of Simultaneous Transcarotid Revascularization With Flow Reversal and Coronary Artery Bypass Grafting for Concomitant Carotid Artery Stenosis and Coronary Artery Disease.

The management of patients with combined severe carotid artery and coronary artery disease (CAD) is controversial. Transcarotid stenting with flow reversal (TCAR) is a novel hybrid technique for carotid revascularization. We sought to investigate the safety and feasibility of simultaneous TCAR and coronary artery bypass grafting (CABG) for concomitant carotid and CAD. A single-institution, retrospective study of patients with critical carotid artery stenosis and symptomatic CAD who underwent simultaneous TCAR-CABG was completed. The primary outcomes were technical success, perioperative stroke, death, and hemorrhage. Four patients underwent TCAR-CABG. All patients were male with a mean age of 64. Technical success was achieved in all cases. There were no perioperative strokes or deaths. There were no reexplorations for hemorrhage. Transcarotid stenting with flow reversal-CABG is a technically feasible hybrid approach for simultaneous carotid and coronary revascularization. It should be part of the vascular surgeon's armamentarium for coexisting carotid and coronary disease. Further research focused on patient selection and perioperative antiplatelet management is warranted prior to the widespread adoption of this technique.

Safety of elective laparoscopic cholecystectomy in patients with antiplatelet therapy: Lessons from more than 800 operations in a single tertiary referral institution.

The perioperative antiplatelet management of patients receiving antiplatelet therapy (APT) for elective laparoscopic cholecystectomy (LC) is still controversial. A total of 808 patients who underwent elective LC were reviewed. We classified patients in this cohort into three groups according to thromboembolic risks: patients with no thromboembolic risk (non-APT group, n = 653), patients with low thromboembolic risk (APT-LR group, n = 106), patients with high thromboembolic risk (APT-HR group, n = 49). Our perioperative management of patients with high thrombotic risks included preoperative continuation of single aspirin therapy and early postoperative reinstitution. We assessed intraoperative and postoperative bleeding/thrombotic events among three groups. Primary outcome measures were intraoperative bleeding complications (IBCs, blood loss 200 mL or more) and postoperative bleeding complications (PBCs), and the independent risk factors for increased IBC were determined by multivariate analysis. This study was approved by our institutional review board (#17011804). In the current cohort, IBC occurred in 17 (2.1%) patients. Postoperatively, there were three PBCs (0.4%) and two thromboembolic complications (TCs, 0.2%), respectively. The occurrences of IBC and TC did not show any significant difference between the three groups, but PBC was more common in the APT-LR group (P = 0.022). Multivariate analysis showed that only chronic cholecystitis was the independent risk factor for IBC (P < 0.001, odds ratio = 12.355), but preoperative continuation of APT or multiple APT use did not affect IBC. We performed elective LC safely in patients receiving APT under rigorous perioperative management of APT. Continuation of aspirin monotherapy is considered in patients with APT during elective LC.

Perioperative Management of Antiplatelets in Elective Surgery at a Tertiary Hospital

Background: Many undergoing elective surgery receive antiplatelets for cardiovascular secondary prevention. European Society of Cardiology (ESC) Guidelines (2017) outlined factors to assist perioperative management of antiplatelets in elective surgery. Aims: Evaluate: 1. Perioperative management of patients taking antiplatelets. 2. Bleeding, thrombosis & rehospitalisation rates. 3. Compliance with Guidelines. Methods: Retrospective analysis of adults undergoing elective surgery from 01/01/2017–01/04/2018 who received antiplatelets pre-operatively. Compliance with ESC Guidelines was rated according to thrombosis and bleeding risk factors. Results: Evaluated 182 patients, age 69 ± 12 years. Interrupting antiplatelets was compliant in 76.4%, duration of cessation was compliant in 26.4%. No difference between antiplatelet type/combinations and compliance was found. Of the 134 non-compliant patients, 73.1% had antiplatelets ceased later than advised. Aspirin cessation was closer to surgery than advised (80.3%, p = 0.027) and associated with increased bleeding (83.1%, p = 0.004). Clopidogrel monotherapy was associated with reduced bleeding (33.3%, p = 0.017). Less bleeding occurred in patients with gastro-oesophageal reflux disease: 17/26 (65%) vs 54/64 (84%) (p = 0.046). Cardiac surgery was associated with increased bleeding (89.0%, p < 0.001) despite higher compliance for interrupting or continuing antiplatelets (85.4%, p < 0.01). Thromboembolism occurred in 2 (1.1%), transfusion in 32 (17.6%), and 14 (7.7%) required rehospitalisation within 3 months. Conclusion: There is considerable compliance with recommendations regarding interruption/continuation of antiplatelets, but widespread discordance concerning duration of antiplatelet interruption, suggesting requirements for further Guideline dissemination/education.

Effect of Perioperative Antiplatelet Management on Thromboembolic Complications after Liver Resection

AIM: The aim of the study was to specify the effect of perioperative antiplatelet (APT) management on postoperative thromboembolism (TE) after livr resection. METHODS: Consecutive 398 patients undergoing liver resection at our hospital from 2005 to 2017 were retrospectively reviewed. Our perioperative antithrombotic management protocol includes preoperative aspirin monotherapy for patients with high thromboembolic risks. Among them, 125 patients (31.4%) had atherosclerotic thromboembolic risk and received APT. The cohort was classified into three groups; patients without APT (N-APT group), APT-discontinued patients (D-APT group), and aspirin-continued patients (C-APT group), The predicted risk of each group was assessed by CHADS2 score, and the rates of TE were compared between the groups. RESULTS: Significantly lower CHADS2 score of N-APT group was observed compared to those of other groups, although the D-APT and C-APT groups had similar distribution of the scores. Among 398 patients, postoperative TE was found in 6 cases (1.5%). Three cases resulted in in-hospital death and other 3 patients were discharged with moderate to severe sequelae. More TE occurred in the D-APT group (4.2%), whereas only one case in the C-APT group (1.9%) and three cases in the N-APT group (0.7%) were observed (p=0.038). Although having high CHADS2 scores, patients in C-APT group showed a relatively low rate of postoperative TE events, mainly due to the preventive effect of preoperative aspirin continuation against TE. CONCLUSION: Liver resection should be performed under rigid perioperative antithrombotic management in order to avoid thromboembolic complications. Especially in patients with APT for thrombotic risks, it is suggested that management with continued preoperative single aspirin therapy should be considered regardless of TE risks.

Perioperative management of patients who are receiving antiplatelet therapy: a case-based, evidence-informed approach.

Addressing the optimal management approach for patients who are receiving single or dual antiplatelet therapy is a common and sometimes challenging clinical problem, especially for patients with coronary stents who are receiving dual antiplatelet therapy with acetylsalicylic acid (ASA) combined with a P2Y12 inhibitor. Using a case-based format, we summarize the findings of recent clinical trials and key observational studies which help inform best practices for the perioperative antiplatelet management of noncardiac surgery and coronary artery bypass graft surgery. In this review, we explore the evidence to address 3 key questions: What is the minimum duration that a surgery should be delayed after coronary stent implantation? In patients who are receiving single antiplatelet therapy with ASA, how to manage patients who require noncardiac and cardiac surgery? In patients who are receiving dual antiplatelet therapy for a coronary stent, how to manage patients who require noncardiac and cardiac surgery?

Preoperative continuation of aspirin administration in patients undergoing major abdominal malignancy surgery.

In contrast to that in a nonoperative setting, it has been shown that perioperative administration of aspirin did not decrease the rate of death or myocardial infarction but increased major bleeding risk. Since these conflicting results might be due to concurrent use of anticoagulants and a lower thrombotic risk of patients, this cohort study was carried out for patients at a high thrombotic risk without concurrent use of anticoagulants. Medical records for patients who underwent major abdominal malignancy surgery and who were on a preoperative antiplatelet regimen were reviewed. The patients were divided into two groups according to perioperative antiplatelet management: administration of all preoperative antiplatelet agent-suspended (no aspirin) group and only aspirin administration-continued (aspirin) group. The incidence of symptomatic thromboembolic events, frequency of exogenous blood transfusion within 30 days after surgery and the amount of intraoperative bleeding were compared between the two groups. After propensity score matching, 105 patients of each group were matched. The incidence of perioperative thromboembolic events in the no-aspirin group was significantly higher than that in the aspirin group [7/105 (6.7%) vs 0/105 (0%), 95% CI 1.44-∞, P = 0.016]. In contrast, neither the frequency of exogenous transfusion [21.0% vs 11.4%, 95% CI 0.88-4.38 P = 0.110] nor the amount of intraoperative bleeding [median (interquartile range), ml: 230 (70-500) vs 208 (50-500), P = 0.325] was different between the two groups. Although the sample size is relatively small, our findings suggest that continuation of aspirin administration is likely to reduce the thrombotic risk but unlikely to increase the bleeding risk of patients who undergo major abdominal surgery for malignancy.

A retrospective study showing the extent of compliance with perioperative guidelines in patients with coronary stents with regard to double antiplatelet therapy

Study objectiveTo evaluate perioperative dual antiplatelet therapy management in patients with previously placed coronary stents. DesignRetrospective medical record review. SettingAcademic medical center. PatientsA total of 1891 surgical cases performed at Vanderbilt University Medical Center in 2012 were evaluated using a perioperative database. Of these, 161 had complete data records that were evaluated using 2 evidence-based and expert opinion–supported protocols. InterventionsN/A. MeasurementsThis study is meant to evaluate perioperative antiplatelet management decisions in patients with coronary stents. Main resultsManagement decisions were consistent with guidelines regarding antiplatelet therapy in 13% (21/161) of patients. Of the 87% (140/161) of cases where decisions were not consistent, 88% (123/140) were due to discontinuing aspirin preoperatively when there was not a high risk of surgical bleeding. ConclusionsThis study revealed suboptimal adherence to current perioperative antiplatelet management guidelines in patients with coronary stents. The lack of adherence to current guidelines is concerning and could be used to support the notion of an anesthesiologist-led Perioperative Surgical Home.

What is the optimal perioperative management of antiplatelet therapy?

What is the optimal perioperative management of antiplatelet therapy?

Perioperative Management of Antiplatelets and Anticoagulants Among Patients Undergoing Elective Transurethral Resection of the Prostate--A Single Institution Experience.

To evaluate current practice in the perioperative management of antiplatelets (AP) and anticoagulants (AC) among men undergoing elective transurethral resection of the prostate (TURP), as well as the associated perioperative bleeding and thromboembolic complications. Retrospective review of consecutive elective TURP patients in a single tertiary institution from January 2011 to December 2013 (n = 293). Data on the regular use of AP/AC and the perioperative management approach were collected from patients' electronic medical records. Bleeding and thromboembolic complications were assessed up to 30 days postoperative. Association between AP/AC use and perioperative complications was assessed using the Kruskall-Wallis test (continuous variables) and the Fisher exact test (categoric variables). There were 107/293 (37%) patients receiving long-term AP while there were 25/293 (9%) patients receiving long-term AC. A total of 72/107 (67%) patients ceased AP on an average of 7.6 days preoperatively, while 35/107 (33%) continued receiving AP. Patients with coronary stents (62%) and coronary bypass graft (67%) were significantly more likely to continued receiving AP (P < 0.001). AC was ceased in all patients preoperatively, with 16/25 (64%) receiving enoxaparin bridging. Overall, there were 31 (10%) incidents of bleeding complications and 5 (2%) thromboembolic events. AC users who had enoxaparin bridging had significantly higher risk of bleeding complications (44%), compared with non-AP/AC users (8%), AP users who ceased AP (4%), AP users who continued receiving AP (17%), and AC users who did not receive enoxaparin bridging (0%) (P < 0.001). AC users who received enoxaparin bridging also reported significantly higher thromboembolic complications (17%; P < 0.001) and prolonged hospital stay (mean 5.4 days) (P = 0.002), compared with other patients. Perioperative management of AP/AC should be based on the indications and the American College of Chest Physicians thromboembolic risk stratification. Regular AC users who had enoxaparin bridging are at increased risk of both perioperative bleeding and thromboembolic complications.

Significant Differences between Vascular and Nonvascular Surgeons in the Perioperative Management of Antiplatelet Therapies in Patients with Coronary Stents

An increasing number of patients undergoing noncardiac surgery have coronary stents. Although guidelines regarding perioperative management of antiplatelet therapies in this patient population exist, practice patterns remain incompletely understood. This study evaluated these practice patterns, with particular attention to differences in management between vascular and nonvascular surgeons. A link to a 16-question survey was displayed in the American College of Surgeons (ACS) electronic newsletter NewsScope, which is posted on the ACS Web site. Questions were focused on perioperative management of antiplatelets (aspirin, clopidogrel) for bare-metal (BMS; placed within 2 months) and drug-eluting stents (DES; placed within the past year) during low- and high-risk bleeding procedures, assuming a patient with no other confounding medical issues. Primary stratification was by surgeon specialty. A total of 244 surgical providers responded to the survey, of which 40 (17%) were vascular surgeons. The majority of respondents were attending surgeons in practice for at least 10 years (79%, n = 190). A significantly higher percentage of vascular versus nonvascular surgeons would not stop aspirin preoperatively in low bleeding risk procedures (BMS: 90% vs. 54%, P = 0.001; DES: 88% vs. 58%, P = 0.009). A higher percentage of vascular surgeons would not stop aspirin preoperatively in high bleeding risk procedures as well (BMS: 70% vs. 28%, P < 0.001; DES: 78% vs. 32%, P < 0.001). Most vascular surgeons would not stop clopidogrel in a low-risk BMS patient (53% vs. 21% of nonvascular surgeons, P = 0.001). Similar findings with clopidogrel were observed in low- (would not stop: 65% vascular versus 30% nonvascular, P < 0.001) and high-risk DES patients (would not stop: 30% vascular versus 8% nonvascular, P = 0.001). The same trends were observed in resuming antiplatelets in the postoperative period. The majority of respondents were not familiar with professional guidelines regarding perioperative antiplatelet management (52%, n = 128), with no differences between vascular and nonvascular surgeons (45% vs. 54%, P = 0.30). This national survey demonstrates significant variation in perioperative antiplatelet management in patients with coronary stents, with marked differences between vascular and nonvascular surgeons. More effective communication of existing guidelines or the development of new specialty-specific professional guidelines appears prudent in reducing this variability in practice.

Incidence of pocket hematoma after electrophysiological device placement: dual antiplatelet therapy versus low-molecular-weight heparin regimen.

BackgroundGiven the increasing number of patients who require dual antiplatelet (DAP) therapy and electrophysiological device (EPD) placement, perioperative antiplatelet management is a current challenge. In this study, we investigated the incidence of pocket hematoma formation after EPD placement in patients undergoing DAP therapy or an alternative low-molecular-weight heparin (LMWH) regimen.MethodsThis clinical observational study was performed from July 2010 to July 2012. In total, 171 patients were enrolled in the analysis after meeting the inclusion criteria. These patients were divided into two groups: 86 patients were treated with DAP therapy at the time of device implantation, and the DAP therapy was discontinued for 5 to 7 days and replaced with enoxaparin before device implantation in the other 85 patients. Adenosine phosphate (ADP)-mediated platelet aggregation and arachidonic acid-induced platelet aggregation were tested preoperatively. We compared the incidence of pocket hematoma between the two groups and the association of pocket hematoma development with ADP-mediated platelet aggregation and arachidonic acid-induced platelet aggregation.ResultsThe incidence of pocket hematoma in the patients who continued DAP was lower than that in the patients who replaced the dual antiplatelet regimen with LMWH (3.49% vs. 16.47%, respectively; X2 = 6.66, P < 0.01). Among the patients who continued DAP therapies, the rate of ADP-mediated platelet aggregation inhibition in patients with pocket hematomas was higher than that in patients without pocket hematomas. None of the patients undergoing DAP or enoxaparin therapy developed pocket infection, thromboembolic events, or other serious complications. Multiple logistic regression analysis revealed that LMWH therapy was an independent risk factor for the development of pocket hematoma (RR = 0.054, 95%CI = 0.012–0.251). Furthermore, patients undergoing LMWH therapy were 5.1-fold more likely to develop pocket hematomas than were DAP-treated individuals.ConclusionContinuance of DAP therapy does not increase the risk of pocket hematoma formation after EPD placement.

Late and very late drug-eluting stent thrombosis in the immediate postoperative period after antiplatelet withdrawal: a retrospective study.

Late (31-360 days after deployment) and very late (>360 days after deployment) stent thrombosis is a feared complication after drug-eluting stent (DES) deployment. The American College of Cardiology/American Heart Association guidelines recommend dual antiplatelet therapy for 12 months due to the lack of protection beyond this period in randomized trials. The perioperative period is a unique state of generalized hypercoagulability which can predispose people to DES thrombosis when combined with the rebound hypercoagulable effect of antiplatelet withdrawal. A retrospective chart review was performed to detect incidences of late and very late postoperative DES thrombosis after elective noncardiac surgery. Only definite and probable cases of stent thrombosis were included. All cases were analyzed for patient demographics, comorbidities, type of surgery, intervention history, preoperative antiplatelets management, postoperative course and outcome. A total of six patients with prior DES deployment (10-42 months earlier, average 30 months) developed DES thrombosis (five very late and one late) in the immediate postoperative period. All patients had stable coronary artery disease and were cleared for surgery (intermediate cardiac risk surgery) by their cardiologist. In all patients, antiplatelets were discontinued 4-7 days (average 5.6 days) prior to surgery to minimize operative bleeding. Five of six patients developed ST-segment elevation myocardial infarction. Half of the patients had simultaneous two-vessel DES thrombosis and two cases had single vessel thrombosis. Three patients developed ventricular fibrillation and cardiac arrest. One-third of the patients died during the index hospitalization. Coronary thrombectomy and angioplasty was successful in the remaining four cases. The incidence of postoperative late and very late DES thrombosis among all patients undergoing noncardiac surgery who were older than 40 years was 0.006%. Caution should be exercised when attempting to withdraw antiplatelets preoperatively in patients with DES even when the recommended 12-month period of dual antiplatelet therapy (DAPT) has elapsed. The significant morbidity and mortality of this complication warrants further research to study the ideal perioperative management of antiplatelets in patients with prior DES deployment over 1 year who are still receiving DAPT.

Perioperative Management of Antiplatelet Therapy in Patients With a Coronary Stent Who Need Noncardiac Surgery: A Systematic Review of Clinical Practice Guidelines

It is unclear how to appropriately manage discontinuation and resumption of antiplatelet therapy in patients with coronary stents who need noncardiac surgery. We undertook a systematic review of the literature to identify practice guideline statements regarding antiplatelet therapy in patients with coronary stents undergoing noncardiac surgery. We used six search strategies to identify practice guideline statements that comment on perioperative antiplatelet management for patients with coronary stents undergoing noncardiac surgery. Two independent reviewers assessed study eligibility, abstracted data, and completed quality assessment. We identified 11 practice guidelines that met the eligibility criteria; these were included in the review. These guidelines advised that elective noncardiac surgery be delayed for at least 4 weeks after bare-metal stent implantation and at least 6 months after drug-eluting stent implantation. For elective surgery, all guidelines advised continuing acetylsalicylic acid (ASA) therapy whenever possible. If interruption of antiplatelet therapy was required, four guidelines advised to discontinue ASA/clopidogrel at least 5 days before surgery, while two guidelines advised to discontinue 7 to 10 days before surgery. Five guidelines provided varying guidance for the use of perioperative bridging during antiplatelet therapy interruption. Most current recommendations are based on expert opinion. This review highlights the need for well-designed prospective studies to identify optimal management strategies in patients with coronary stents who are on antiplatelet therapy and who need noncardiac surgery.

Perioperative management of antiplatelet therapy

Worldwide, cardiovascular events represent the major cause of morbidity and mortality. A key role in the pathogenesis of these events is played by platelets. Interventional procedures, with placement of coronary and vascular stents, often represent the preferred therapeutic strategy. Antiplatelet medications are considered first-line therapy in preventing cardiovascular thrombotic events. A wide array of antiplatelet agents is available, each with different pharmacological properties. When patients on antiplatelet agents present for surgery, the perioperative team must design an optimal strategy to manage antiplatelet medications. Each patient is stratified according to risk of developing a cardiovascular thrombotic event and inherent risk of surgical bleeding. After risk stratification analysis, various therapeutic pathways include continuing or discontinuing all antiplatelet agents or maintaining one antiplatelet agent and discontinuing the other. This review focuses on the pharmacological and pharmacokinetic properties of both older and novel antiplatelet drugs, and reviews current literature and guidelines addressing options for perioperative antiplatelet management.