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J Am Coll Cardiol, 2000; 35:1288-1294
© 2000 by the American College of Cardiology Foundation
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ARTICLE

Catastrophic outcomes of noncardiac surgery soon after coronary stenting

Grzegorz L. Kaluza, MD, PhDa, Jane Josepha, Joseph R. Lee, MDa, Michael E. Raizner, MDa and Albert E. Raizner, MD, FACCa

a Methodist Hospital, Baylor College of Medicine, Houston, Texas, USA

Manuscript received May 11, 1999; revised manuscript received September 20, 1999, accepted December 15, 1999.

Reprint requests and correspondence: Dr. Albert E. Raizner, The Methodist Hospital, 6535 Fannin, MS F1034, Houston, Texas 77030
araizner{at}msn.com

OBJECTIVES

To assess the clinical course of patients who have undergone coronary stent placement less than six weeks before noncardiac surgery.

BACKGROUND

Surgical and percutaneous transluminal coronary angioplasty revascularization performed before high-risk noncardiac surgery is expected to reduce perioperative cardiac morbidity and mortality. Perioperative and postoperative complications in patients who have undergone coronary stenting before a noncardiac surgery have not been studied.

METHODS

Forty patients who underwent coronary stent placement less than six weeks before noncardiac surgery requiring a general anesthesia were included in the study (1–39 days, average: 13 days). The records were screened for the occurrence of adverse clinical events, including myocardial infarction, stent thrombosis, peri- and postoperative bleeding and death.

RESULTS

In 40 consecutive patients meeting the study criteria, there were seven myocardial infarctions (MIs), 11 major bleeding episodes and eight deaths. All deaths and MIs, as well as 8/11 bleeding episodes, occurred in patients subjected to surgery fewer than 14 days from stenting. Four patients expired after undergoing surgery one day after stenting. Based on electrocardiogram, enzymatic and angiographic evidence, stent thrombosis accounted for most of the fatal events. The time between stenting and surgery appeared to be the main determinant of outcome.

CONCLUSIONS

Postponing elective noncardiac surgery for two to four weeks after coronary stenting should permit completion of the mandatory antiplatelet regimen, thereby reducing the risk of stent thrombosis and bleeding complications.

Abbreviations and Acronyms
  CABG = coronary artery bypass grafting
  CAD = coronary artery disease
  CX = circumflex coronary artery
  ECG = electrocardiogram
  LAD = left anterior descending coronary artery
  MI = myocardial infarction
  OM = obtuse marginal branch
  PTCA = percutaneous transluminal coronary angioplasty
  RCA = right coronary artery




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E. O. McFalls, H. B. Ward, T. E. Moritz, S. Goldman, W. C. Krupski, F. Littooy, G. Pierpont, S. Santilli, J. Rapp, B. Hattler, et al.
Coronary-Artery Revascularization before Elective Major Vascular Surgery
N. Engl. J. Med., December 30, 2004; 351(27): 2795 - 2804.
[Abstract] [Full Text] [PDF]


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SEMIN CARDIOTHORAC VASC ANESTHHome page
J. N. Ghansah and J. T. Murphy
Complications of Major Aortic and Lower Extremity Vascular Surgery
Seminars in Cardiothoracic and Vascular Anesthesia, December 1, 2004; 8(4): 335 - 361.
[Abstract] [PDF]


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HeartHome page
F Alfonso, A Suarez, D J Angiolillo, M Sabate, J Escaned, R Moreno, R Hernandez, C Banuelos, and C Macaya
Findings of intravascular ultrasound during acute stent thrombosis
Heart, December 1, 2004; 90(12): 1455 - 1459.
[Abstract] [Full Text] [PDF]


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CirculationHome page
J.P. Collet, G. Montalescot, B. Blanchet, M.L. Tanguy, J.L. Golmard, R. Choussat, F. Beygui, L. Payot, N. Vignolles, J.P. Metzger, et al.
Impact of Prior Use or Recent Withdrawal of Oral Antiplatelet Agents on Acute Coronary Syndromes
Circulation, October 19, 2004; 110(16): 2361 - 2367.
[Abstract] [Full Text] [PDF]


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ChestHome page
U. K. H. Wiegand, D. LeJeune, F. Boguschewski, H. Bonnemeier, F. Eberhardt, H. Schunkert, and F. Bode
Pocket Hematoma After Pacemaker or Implantable Cardioverter Defibrillator Surgery: Influence of Patient Morbidity, Operation Strategy, and Perioperative Antiplatelet/Anticoagulation Therapy
Chest, October 1, 2004; 126(4): 1177 - 1186.
[Abstract] [Full Text] [PDF]


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Arch Intern MedHome page
A. F. Hernandez, L. K. Newby, and C. M. O'Connor
Preoperative Evaluation for Major Noncardiac Surgery: Focusing on Heart Failure
Arch Intern Med, September 13, 2004; 164(16): 1729 - 1736.
[Abstract] [Full Text] [PDF]


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Br J AnaesthHome page
D. E. Newby and A. F. Nimmo
Editorial II: Prevention of cardiac complications of non-cardiac surgery: stenosis and thrombosis
Br. J. Anaesth., May 1, 2004; 92(5): 628 - 632.
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Br J AnaesthHome page
C. Marcucci, P.-G. Chassot, J.-P. Gardaz, L. Magnusson, H.-B. Ris, A. Delabays, and D. R. Spahn
Fatal myocardial infarction after lung resection in a patient with prophylactic preoperative coronary stenting{dagger}
Br. J. Anaesth., May 1, 2004; 92(5): 743 - 747.
[Abstract] [Full Text] [PDF]


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ANN INTERN MEDHome page
G. W. Smetana, S. L. Cohn, and V. A. Lawrence
Update in Perioperative Medicine
Ann Intern Med, March 16, 2004; 140(6): 452 - 461.
[Full Text] [PDF]


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J Am Coll CardiolHome page
C. E. Mendoza, N. Shah, and S. Virani
Percutaneous coronary intervention before noncardiac surgery: more threat than benefit?
J. Am. Coll. Cardiol., February 18, 2004; 43(4): 713 - 714.
[Full Text] [PDF]


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J Am Coll CardiolHome page
J. Auer, R. Berent, T. Weber, and B. Eber
Risk of noncardiac surgery in the months following placement of a drug-eluting coronary stent
J. Am. Coll. Cardiol., February 18, 2004; 43(4): 713 - 713.
[Full Text] [PDF]


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CirculationHome page
R. Mehran, E. D. Aymong, D. T. Ashby, T. Fischell, H. Whitworth Jr, R. Siegel, W. Thomas, S. C. Wong, R. Narasimaiah, A. J. Lansky, et al.
Safety of an Aspirin-Alone Regimen After Intracoronary Stenting With a Heparin-Coated Stent: Final Results of the HOPE (HEPACOAT and an Antithrombotic Regimen of Aspirin Alone) Study
Circulation, September 2, 2003; 108(9): 1078 - 1083.
[Abstract] [Full Text] [PDF]


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J Am Coll CardiolHome page
S. H. Wilson, P. Fasseas, J. L. Orford, R. J. Lennon, T. Horlocker, N. E. Charnoff, S. Melby, and P. B. Berger
Clinical outcome of patients undergoing non-cardiac surgery in the two months following coronary stenting
J. Am. Coll. Cardiol., July 16, 2003; 42(2): 234 - 240.
[Abstract] [Full Text] [PDF]


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CirculationHome page
D. Mukherjee and K. A. Eagle
Perioperative Cardiac Assessment for Noncardiac Surgery: Eight Steps to the Best Possible Outcome
Circulation, June 10, 2003; 107(22): 2771 - 2774.
[Full Text] [PDF]


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Anesth. Analg.Home page
L. Glantz, T. Ezri, Y. Cohen, S. Konichezky, A. Caspi, D. Geva, and A. Leviav
Perioperative Myocardial Ischemia in Patients Undergoing Sternectomy Shortly After Coronary Artery Bypass Grafting
Anesth. Analg., June 1, 2003; 96(6): 1566 - 1571.
[Abstract] [Full Text] [PDF]


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ANN INTERN MEDHome page
P. A. Grayburn and L D. Hillis
Cardiac Events in Patients Undergoing Noncardiac Surgery: Shifting the Paradigm from Noninvasive Risk Stratification to Therapy
Ann Intern Med, March 18, 2003; 138(6): 506 - 511.
[Abstract] [Full Text] [PDF]


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Anesth. Analg.Home page
M. Licker, G. Khatchatourian, A. Schweizer, M. Bednarkiewicz, D. Tassaux, and C. Chevalley
The Impact of a Cardioprotective Protocol on the Incidence of Cardiac Complications After Aortic Abdominal Surgery
Anesth. Analg., December 1, 2002; 95(6): 1525 - 1533.
[Abstract] [Full Text] [PDF]


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Br J AnaesthHome page
P.-G. Chassot, A. Delabays, and D. R. Spahn
Preoperative evaluation of patients with, or at risk of, coronary artery disease undergoing non-cardiac surgery
Br. J. Anaesth., November 1, 2002; 89(5): 747 - 759.
[Abstract] [Full Text] [PDF]


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Anesth. Analg.Home page
R. Chun, B. A. Orser, and M. Madan
Platelet Glycoprotein IIb/IIIa Inhibitors: Overview and Implications for the Anesthesiologist
Anesth. Analg., October 1, 2002; 95(4): 879 - 888.
[Full Text] [PDF]


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Anesth. Analg.Home page
L. A. Fleisher and K. A. Eagle
Guidelines on Perioperative Cardiovascular Evaluation: What Have We Learned Over the Past 6 Years to Warrant an Update?
Anesth. Analg., May 1, 2002; 94(5): 1378 - 1379.
[Full Text] [PDF]



 
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