LETTER TO THE EDITOR
Risk of noncardiac surgery in the months following placement of a drug-eluting coronary stent
Johann Auer, MD, FESC,
Robert Berent, MD,
Thomas Weber, MD and
Bernd Eber, MD, FESC
Department of Cardiology and Intensive Care, General Hospital Wels, Grieskirchnerstraße 42, A-4600 Wels, Austria
johann.auer{at}khwels.at
We read with great interest the retrospective study by Wilson et al. (1) in a recent issue of the Journal. The study provides data suggesting that, whenever possible, noncardiac surgery should be delayed six weeks after placement of a coronary stent. By that time a course of antiplatelet therapy to prevent stent thrombosis has usually been completed, and bare metal stents are generally endothelialized.
Today, drug-eluting stents are increasingly utilized to reduce the risk of restenosis. Elution of antiproliferative agents delays endothelialization (2,3), which, consequently, may increase the risk of subacute and late stent thrombosis. Therefore, a prolonged course of antiplatelet therapy has been recommended with the use of drug-eluting stents (4). Thus, the conclusion drawn from the study by Wilson et al. (1) is strictly confined to bare metal stents and is not applicable for drug-eluting stents.
We recently observed a patient who simultaneously received a bare metal stent (3.5 x 13 mm at right coronary artery [RCA]) and two paclitaxel-eluting stents (both 2.5 x 16 mm at the left circumflex coronary artery [LCX]) for stable angina and double-vessel coronary artery disease. A six-month course of combined antiplatelet therapy (clopidogrel 75 mg daily and aspirin 100 mg daily) to prevent stent thrombosis was prescribed. At 12 weeks following stent placement, surgery for meniscopathy at the left knee was performed after cessation of both antiplatelet agents. Two hours following surgery, the patient developed chest pain. Subsequently, myocardial infarction (MI) was confirmed by electrocardiography and by biochemical markers. The patient was transferred to our institution one day after surgery for cardiac catheterization. Coronary angiography revealed total occlusion of both paclitaxel-eluting stents at the LCX. The bare stent at the RCA was unremarkable. Recanalization of the occluded stents was performed successfully.
Stent thrombosis is a highly morbid complication of coronary stenting (5,6). With the use of combined antiplatelet therapy, the frequency of stent thrombosis has been reduced dramatically (7). However, noncardiac surgery soon after coronary stenting is associated with a high rate of MI and death (8). The present data (1) nicely demonstrate that delaying noncardiac surgery for up to six weeks after stent placement and completing a course of antiplatelet therapy with a thienopyridine is associated with a low frequency of stent thrombosis and other adverse events. However, this recommendation has to be strictly confined to bare metal stents. Following drug-eluting stent placement, elective noncardiac surgery should be delayed for several months, by which time those stents are generally endothelialized, and a course of prolonged combined antiplatelet therapy to prevent stent thrombosis has been completed.
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References
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- Wilson SH, Fasseas P, Orford JL, et al. Clinical outcome of patients undergoing non-cardiac surgery in the two months following coronary stenting. J Am Coll Cardiol. 2003;42:234–240[Abstract/Free Full Text]
- Farb A, Heller PF, Shroff S, et al. Pathological analysis of local delivery of paclitaxel via a polymer-coated stent. Circulation. 2001;104:473–479[Abstract/Free Full Text]
- Finkelstein A, McClean D, Kar S, et al. Local drug delivery via a coronary stent with programmable release pharmacokinetics. Circulation. 2003;107:777–784[Abstract/Free Full Text]
- Grube E, Silber S, Hauptmann KE, et al. TAXUS I: six- and twelve-month results from a randomized, double-blind trial on a slow-release paclitaxel-eluting stent for de novo coronary lesions. Circulation. 2003;107:38–42[Abstract/Free Full Text]
- Haude M, Erbel R, Issa H, et al. Subacute thrombotic complications after intracoronary implantation of Palmaz-Schatz stents. Am Heart J. 1993;126:15–22[Medline]
- Malenka DJ, O'Rourke D, Miller MA, et al. Cause of in-hospital death in 13,232 consecutive patients undergoing percutaneous transluminal coronary angioplasty. Am Heart J. 1999;137:632–638[CrossRef][Medline]
- Wilson S, Rihal CS, Bell MR, et al. Timing of coronary stent thrombosis in patients treated with ticlopidine and aspirin. Am J Cardiol. 1999;83:1006–1011[CrossRef][Medline]
- Kaluza GL, Joseph J, Lee JR, Raizner ME, Raizner AE. Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol. 2000;35:1288–1294[Abstract/Free Full Text]
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