ANESTHESIA FOR PATIENTS WITH CORONARY STENTS FOR NON CARDIAC SURGERY

Dr. Mahesh Vakamudi

Professor and Head
Department of Anesthesiology, Critical Care and Pain Medicine
Sri Ramachandra ni!ersity
INTRODUCTION
Appro"imately #$ of patients %ith intracoronary stents %ill undergo non cardiac surgery %ithin the first
year after stenting, and an increasing num&er %ill continue to present for surgery thereafter. As the
success of the stents re'uires long(term antiplatelet therapy, management of patients %ith these
de!ices poses a dilemma to the anesthesiologist. Discontinuation of antiplatelet therapy relati!ely soon
after PC) *percutaneous coronary inter!ention+ %ith stenting confers significant mortality during non
cardiac surgery. As stent endotheliali,ation may not yet &e complete at the time of surgery, a&rupt
discontinuation of antiplatelets com&ined %ith the prothrom&otic state induced &y surgery increases
the risk of acute perioperati!e stent throm&osis *-ig..+ and myocardial infarction. Continuation of
antiplatelet medications may &e associated %ith an increased risk of intraoperati!e &leeding and also
pre!ent administration of regional anesthesia.
As per the /001 -ocused pdate of the ACC2AHA2SCA) /00# 3uideline pdate for Percutaneous
Coronary )nter!ention, all post(PC) stented patients recei!ing a D4S *drug eluting stent+, clopidogrel 1#
mg daily should &e gi!en for at least ./ months if patients are not at high risk of &leeding. -or post(PC)
patients recei!ing a 5MS *&are metal stent+, clopidogrel should &e gi!en for a minimum of . month
and ideally up to ./ months *unless the patient is at increased risk of &leeding6 then it should &e gi!en
for a minimum of / %eeks+. (Level of Evidence: B)
7hey also recommend postponing all electi!e procedures for %hich there is a significant risk of &leeding
until dual(antiplatelet therapy is completed *7a&le .+.
Aspirin is continued throughout the perioperati!e period, e"cept in instances %here surgery is
performed in closed space *intracranial surgery, posterior cham&er of the eye, spinal surgery in the
medullary canal+.
7he su&stitution of non selecti!e 8SA)Ds and 9M:H for dual(antiplatelet therapy is contro!ersial and
there is no scientific e!idence to support their efficacies in pre!enting perioperati!e stent throm&osis.
7he concomitant use of non selecti!e 8SA)Ds and aspirin significantly increases cardiac mor&idity and
mortality in patients %ith coronary artery disease and the incidence may &e e!en higher in patients %ith
coronary stents. Although heparin therapy is often used perioperati!ely for throm&oem&olic
prophyla"is, it does not ha!e antiplatelet properties and is not protecti!e against stent throm&osis.
Fig.1. Diagram of the pathophysiology of acute perioperative stent thrombosis
A&rupt discontinuation of clopidogrel A&rupt discontinuation of aspirin
Re&ound effect6
Significantly increased inflammatory prothrom&otic state
Signficantly increased platelet adhesion and aggregation
4"cessi!e throm&o"ane A/ acti!ity
Surgical intervention
Increase !rot"ro#$otic an in%la##ator& state
)ncreased cytokines, neuroendocrine, inflammatory mediator release
)ncreased platelet adhesi!eness and persistently high platelet counts
)ncreased release of procoagulant factors
Decreased2)mpaired fi&rinolysis
Prothrom&otic27hrom&otic state %ith incompletely endotheliali,ed stent*s+
Stent throm&osis
Myocardial infarction
Death
;
;
Table 1. Duration of antiplatelet therapy and timing of noncardiac surgery
To summarize treatment options for patients with DES: (1) continue dual-antiplatelet therapy
throughout the perioperative period for patients at low ris of !leeding (") implement #!ridging
therapy$% in which a short acting &' ((!)(((a inhi!itor (tirofi!an or eptifi!atide) or throm!in
inhi!itor% or !oth% is su!stituted for clopidogrel during the perioperative period* or (+)
discontinue clopidogrel preoperatively% restarting it as soon as possi!le postoperatively, &'
((!)(((a inhi!itors have !een favored since this platelet receptor is the pivotal mediator for
platelet aggregation and throm!us formation, They are more potent than the com!ination of
aspirin and a theinopyridine, &' ((!)(((a inhi!itors are recommended as !ridging therapy
primarily (1) in patients who have not completed dual-antiplatelet therapy and (") in patients
whose stent comple-ities and comor!idities significantly increase their ris for developing
catastrophic stent throm!osis and its se.uelae, Tirofi!an and eptifi!atide are administered
parenterally% have half lives / " h% and are eliminated !y renal clearance, 'latelet function returns
to 012 - 312 of normal after the infusion is stopped for 0 4 5 h,
Dilatation 'it"out stenting< / = > %eek of dual(antiplatelet therapy
Surgery postponed for / = > %eek *!ital surgery only+
PCI an ()S< > = ? %eek minimum of dual( antiplatelet therapy
4lecti!e surgery postponed @ ? %eek, &ut not for more than ./ %eek, %hen
restenosis may &egin to occur
PCI an DES< ./ months of dual(antiplatelet therapy
4lecti!e surgery postponed for @ ./ months
)n patients in %hom coronary re!asculari,ation %ith PC) is appropriate for
mitigation of cardiac symptoms and %ho need electi!e non cardiac surgery in the
su&se'uent ./ months, a strategy of &alloon angioplasty or 5MS placement
follo%ed &y > to ? %eeks of dual(antiplatelet therapy is pro&a&ly indicated
Aspirin< 9ifelong therapy, %hiche!er is the re!asculari,ation techni'ue
Fig.2. Algorithm for perioperative management of patients with bare metal stents
7ime of anticipated surgery
A ? %ks after 5MS implantation B ? %ks after 5MS implantation
4lecti!e
rgent
Postpone surgery until
5MS has &een
implanted ? %eeks
Can clopidogrel and aspirin &e
continued in the perioperati!e
periodC
Continue aspirin throughout surgery
if at all possi&le
Des 8o Consider &ridging therapy
Proceed
Can aspirin &e
continuedC
Des 8o
Consider &ridging therapy
Proceed
Fig.3. Algorithm for perioperative management of patients with drug eluting stents
Management of stent throm&osis:
:hen stent throm&osis occurs, it acutely manifests as a S74M) or a sudden malignant dysrhythmia, and
must &e treated %ith immediate reperfusion to a!oid a transmural M) due to the a&rupt interruption of
coronary &lood flo% in a myocardial region that is neither collaterali,ed nor preconditioned &y recurrent
chronic ischemia. 7hrom&olytic therapy *)V or intracoronary+ is significantly less effecti!e than PC) in
treating stent throm&osis and restoring myocardial perfusion. Administration of throm&olytic therapy is
often prohi&iti!e in the perioperati!e period. 7herefore, primary PC) is the definiti!e treatment for
perioperati!e stent throm&osis and restoration of coronary stent patency. Surgical procedures should &e
performed in institutions %here />(h inter!entional cardiology is a!aila&le to pro!ide immediate and
emergent inter!ention. Postoperati!e management should include admission to a higher(acuity unit
%ith continued electrocardiogram monitoring and cardiology sur!eillance.
Regional anesthesia *RA+<
8eura"ial &lockade attenuates the hypercoagula&le perioperati!e state &y &lunting the sympathetic
response. Systemic a&sorption of local anesthetics pro!ides antiplatelet effects &y &locking 7"A/ and
decreasing platelet aggregation. 7hese &enefits of regional anesthesia are ad!antageous in patients %ith
intracoronary stents. ASRA recommendations ha!e to &e follo%ed to decide %hen RA can &e
administered in patients on antiplatelets.
7he role of perioperati!e platelet transfusions in patients on dual(antiplatelet therapy %hen RA is
considered cannot &e Eustified. 4" !i!o studies ha!e sho%n that transfused platelets may not &e
inhi&ited &y the presence of ade'uate serum le!els of antiplatelet drugs. Moreo!er, the throm&ogenic
surfaces of stents may attract and acti!ate donor platelets to a e!en greater e"tent than endogenous
platelets, further increasing the risk of stent throm&osis, M) and death.
CF8C9S)F8
7he management of patients %ith coronary artery stents during the perioperati!e period is an important
safety issue. Communication &et%een the patientGs cardiologist, surgeon and anesthesiologist is
essential to minimi,e the risk of catastrophic stent throm&osis.