Abstract
The management of patients, who had previously undergone percutaneous coronary interventions (PCI) with or without coronary artery stenting and who are presenting for noncardiac surgery has become a major topic of interest and concern for anesthesiologists worldwide. This review will update recent reports, as well as recommendations for the perioperative care of these patients. The two most commonly used stent types, bare-metal stents (BMSs) and drug-eluting stents (DESs), mandate different lengths of dual antiplatelet drug therapy to avoid stent thrombosis. The risks posed at the time of noncardiac surgery by such patients include acute coronary syndromes, as a result of stent thrombosis, after cessation of anti-platelet therapy and excessive bleeding from continued antiplatelet therapy, particularly when patients undergo surgery early after stent implantation. Pre- and intraoperatively, the risk factors for thrombosis have to be balanced against the risk factors for surgical bleeding. As long as prospective trials are not available, the recommendations and guidelines of task forces and experts are based on retrospective studies and case reports. So based on the available literature, all experts recommend avoiding premature discontinuation of antiplatelet drug therapy if possible except for a few surgical procedures. Drugeluting stents carry more risks than bare-metal stents. It is generally agreed that aspirin must be continued throughout the perioperative period, except in circumstances when the risk of bleeding significantly outweighs the benefit of continued anticoagulation, such as procedures performed in a closed space. Postoperative recommendations are also presented, as the occurrence of perioperative stent thrombosis appears to be greatest during this period. Immediate percutaneous coronary intervention is the definitive treatment for perioperative stent thrombosis, and access to an interventional cardiologist should be available. Algorithms for perioperative management of patients with baremetal and drug-eluting stents are proposed.
