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LETTER TO THE EDITOR

Anticoagulation Management for Patients with Drug-Eluting Stents Undergoing Vascular Surgery

gilles.godet{at}psl.aphp.fr (Charbucinska, Godet) Department of Anesthesiology and Critical Care; Centre Hospitalo-Universitaire Pitié-Salpêtrière; Assistance Publique-Hôpitaux de Paris; Université Pierre et Marie Curie; Paris, France (Itani, Fleron, Bertrand, Rienzo, Coriat)

To the Editor:

More than 1.5 million people benefit each year from percutaneous coronary revascularization with stent insertion. Since their introduction in 2002, many stents elute pharmacologically active drugs to prevent restenosis (1). Recent case reports describe catastrophic perioperative stent thrombosis in patients with drug-eluting stents undergoing noncardiac surgery (2–4). Some data suggest that at least 1 yr of dual antiplatelet therapy (aspirin + clopidogrel) is necessary to prevent stent thrombosis after placement of drug-eluting stents (5,6). Although potent antiplatelet therapy may complicate surgery, taking patients off their antiplatelet therapy for surgery, combined with the general inflammatory response to surgery, may precipitate catastrophic stent thrombosis. We report the perioperative management of anticoagulation and outcome of 15 patients with a drug-eluting stents who underwent 18 vascular interventions in our unit over the last year.

The characteristics of surgery, stent type, and interval plus complication rates are outlined in the Table 1. The perioperative management of anticoagulation varied according to the type of surgery and the associated risk of perioperative hemorrhage. Aspirin was continued for all peripheral surgeries but both aspirin and clopidogrel were stopped for approximately 8 days before aortic surgery. In most of the cases clopidogrel was replaced by low molecular weight heparin started approximately 5 days before surgery. Aspirin was always restarted on postoperative day 1. All patients received low molecular weight heparin in the immediate perioperative period, which was continued until clopidogrel was restarted.

None of the patients had excessive postoperative blood loss. One patient taking clopidogrel and aspirin had a moderate hematoma after carotid endarterectomy, which did not compromise the airway and did not require surgical intervention. Patient 14 had a troponin leak (peak of 0.55 µg/L) on postoperative day 1, without any electrocardiogram abnormality. Patient 5 (procedure A) had a troponin leak (peak of 1.63 µg/L) on postoperative day 2. Coronary angiography on day 5 revealed no new abnormality. He underwent another procedure 7 mo later (procedure B) with similar anticoagulation prophylaxis without any complications. Patient 7 died on the first postoperative day from hypoxic respiratory arrest during fiberoptic bronchoscopy. The patient had severe chronic obstructive pulmonary disease, and the death was not related to any cardiac problem. Patient 9 died 4 wk after a femoral-popliteal bypass (procedure A) requiring subsequent amputation of toes (procedure B). Death occurred after discharge, in the nephrology unit, caused by sepsis and anuria, with a late increased of cardiac tropin I (peak at 11.53 µg/L on the day before death).

Our results confirm that management of antiplatelet therapy in patients with a drug-eluting stents requires carefully balancing the risk of bleeding on antiplatelet therapy with the risk of catastrophic stent stenosis should antiplatelet therapy be withdrawn. In our modest series continuation of aspirin and adding low molecular weight heparin was not associated with any severe postoperative cardiac complications. Further studies are required to develop optimal guidelines for managing antiplatelet therapy in patients with drug-eluting stents.

REFERENCES

1. Kaluza GL, Joseph J, Lee JR, et al. Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol 2000;35:1288–94.[Abstract/Free Full Text]
2. Fleron MH, Dupuis M, Mottet P, et al. Non cardiac surgery in patient with coronary stenting: think sirolimus now! [in French]. Ann Fr Anesth Reanim 2003;22: 733–5.[Web of Science][Medline]
3. McFadden EP, Stabile E, Regar E, et al. Late thrombosis in drug-eluting coronary stents after discontinuation of antiplatelet therapy. Lancet 2004;364:1519–21.[Web of Science][Medline]
4. Murphy JT, Fahy BG. Thrombosis of sirolimus-eluting coronary stent in the post anesthesia care unit. Anesth Analg 2005;101:971–3.[Abstract/Free Full Text]
5. Ong AT, McFadden EP, Regar E, et al. Late angiographic stent thrombosis (LAST) events with drug-eluting stents. J Am Coll Cardiol 2005;45:2088–92.[Abstract/Free Full Text]
6. Zimarino M, Renda G, De Caterina R. Optimal duration of antiplatelet therapy in recipients of coronary drug-eluting stents. Drugs 2005;65:725–32.[Web of Science][Medline]

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