Brief review: Coronary drug-eluting stents and anesthesia

Abstract

Purpose: Anesthesiologists managing patients with drug-eluting stents (DES) face the challenge of balancing the risks of bleeding vs 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. Objectif

Atypical presentation of an epidural hematoma in a patient receiving aspirin and low molecular weight heparin. Was epidural analgesia the right choice?

“…However, individual variation amongst clinicians does exist. With the increasing use of acetylsalicylic acid therapy in patients with preexisting cardiac disease, more patients in whom it is advisable to continue acetylsalicylic acid therapy perioperatively, such as patients with coronary stents, will be encountered [14]. Recognizing that this individual case report does not prove causation, in patients who require concurrent perioperative acetylsalicylic acid therapy and LMWH, we strongly suggest that regional analgesia with an indwelling catheter be avoided and alternative methods of pain relief explored.…”

Stents coronarios y cirugía no cardiaca: estrategias de manejo actual

“…Si es posible, debe mantenerse aspirina y suspenderse clopidogrel, para reiniciarse lo antes posible en el postoperatorio. En caso de cirugía electiva después de la inserción de un SNM debe realizarse entre la 6ª y 12ª semana y después de un SM debe esperarse un año [17][18][19][20][21][22][23][24][25] . Para cirugías de urgencia no es posible esperar, la sugerencia es mantener el tratamiento antiplaquetario dual, pero si el riesgo de sangrado es muy alto debe suspenderse y reiniciarse prontamente en el postoperatorio 29 .…”

“…Debe considerarse terapia "puente" en casos de alto riesgo de trombosis del SC así como en cirugías con alto riesgo de hemorragia 24 . El uso de heparinas de cualquier tipo ha sido descrita, sin embargo, no hay evidencia claras de que sean siempre efectivas, fundamentalmente porque no tienen actividad antiplaquetaria 27 .…”

Questions non résolues concernant la stratification du risque et la prise en charge des patients atteints de maladie coronarienne subissant une chirurgie vasculaire majeure

“…64,65 However, if such antiplatelet therapy is maintained, the risk of bleeding may be increased following the surgery. 64,66,67 Moreover, compared to patients without PAD, patients with PAD are at an increased risk of death and MI after PCI. 68 Finally, CAbG, which is associated with a 2 to 4% risk of perioperative death, 46 did not improve long-term survival in the CARP trial.…”