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J Am Coll Cardiol, 2007; 50:1398, doi:10.1016/j.jacc.2007.05.043 (Published online 14 September 2007).
© 2007 by the American College of Cardiology Foundation
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CORRESPONDENCE: LETTER TO THE EDITOR

Revascularization Before Noncardiac Surgery: Is There an Impact of Drug-Eluting Stent Thrombosis?

Philippe Gabriel Steg, MD, FESC, FACC, FACCP*

* Cardiologie, Hopital Bichat, 46 rue H Huchard, Paris 18, Cedex 75877, France 75018 (Email: gabriel.steg{at}bch.ap-hop-paris.fr).

I read with great interest the randomized pilot study of Poldermans et al. (1), which suggests that there may be no benefit to a strategy of preoperative coronary revascularization, even in high-risk patients with extensive ischemia, before major vascular surgery. The authors should be commended for performing this and other landmark studies in the field. As pointed out by the authors, the apparent lack of benefit of coronary revascularization in this setting is not fully understood. Among the 49 patients in the "revascularization" arm, 32 underwent percutaneous coronary intervention and stenting, and drug-eluting stents were used in 30. In the context of surgery early after stenting, stent thrombosis is a concern, particularly if drug-eluting stents were used, and may underlie catastrophic events in the perioperative period (2). Despite the fact that aspirin and clopidogrel were continued during surgery in these patients, it would be useful to know whether there was information regarding potential stent thromboses as the mechanisms for some of the events in the revascularization group. Apart from angiographic or autopsy confirmation of stent thrombosis, the mere finding of an abrupt ST-segment elevation myocardial infarction in the territory of a recently implanted drug-eluting stent also may be considered to be important. To help address this issue, the recent Academic Research Consortium report (3) is a first step in helping classify clinical events potentially related to stent thrombosis as certain, probable, or possible. I believe such an analysis of the DECREASE-V events may help shed additional light on the mechanisms for the benefit or lack thereof of revascularization in this context.


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  1. Poldermans D, Schouten O, Vidakovic R, et al. DECREASE Study Group A clinical randomized trial to evaluate the safety of a noninvasive approach in high-risk patients undergoing major vascular surgery: the DECREASE-V pilot study J Am Coll Cardiol 2007;49:1763-1769.[Abstract/Free Full Text]
  2. 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]
  3. Cutlip DE, Windecker S, Mehran R, et al. , Academic Research ConsortiumClinical end points in coronary stent trials: a case for standardized definitions. Circulation 2007;115:2344-2351.[Abstract/Free Full Text]

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Harm H.H. Feringa, Olaf Schouten, Anai E.S. Durazzo, and Don Poldermans
J. Am. Coll. Cardiol. 2007 50: 1399. [Full Text] [PDF]




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