Do percutaneous coronary interventions protect the surgical patient?

Abstract

The number of percutaneous coronary interventions (PCI) performed annually has increased rapidly over the last two decades. Coronary angioplasties are now commonly complemented with the insertion of coronary artery stents. Initially bare metal stents (BMS) were developed with drug-eluting stents (DES) subsequently being introduced. Drug-eluting stents reduce in-stent restenosis at the cost of prolonged anti-platelet therapy. While observational studies suggest that coronary artery bypass graft surgery protects against perioperative cardiac events in non-cardiac surgery, no such evidence exists for PCI. In order to prevent stent thrombosis, patients need to receive dual anti-platelet therapy (generally aspirin and clopidogrel) for four to six weeks with BMS, and at least one year with DES. Patients on dual anti-platelet therapy are at risk of severe bleeding during surgery. However, withdrawal of dual anti-platelet therapy is associated with the risk of stent thrombosis. The risk of cardiac complications seems to exceed the risk of bleeding, and maintenance of dual anti-platelet therapy is advocated whenever possible. Surgery in closed cavities (neurosurgery, intraocular surgery) necessitates the withdrawal of dual anti-platelet therapy. There is a significant risk of perioperative complications in patients who have DES, or recently inserted BMS, and consequently surgery should not be performed without a discussion involving the surgeon, cardiologist, anaesthetist, and the patient. IntroductionOver the past thirty years there have been major advances in the management of patients with coronary artery disease. These have included life style changes, recently complemented in some countries by the ban of smoking in public places, the development of drug strategies including beta-adrenoceptor blockers, angiotensin-converting enzyme inhibitors, statins, aspirin, thrombolysis and early myocardial revascularisation. Coronary artery bypass graft (CABG) surgery has also evolved. Internal mammary arteries and subsequently radial arteries have been utilised alone or in addition to saphenous vein grafts to revascularise the coronary circulation, and CABG surgery may be performed with or without cardiopulmonary bypass. Finally, there has been the rapid development of percutaneous coronary interventions. These advances resulted in a 65% decrease in the death rate among patients below the age of 65 over the period 1970-2002.