11. Catastrophic outcomes of
noncardiac surgery soon after coronary stenting
What is the risk of percutaneous coronary intervention
(PTCA with an intracoronary stent) prior to elective surgery?
Kaluza J Am Coll Cardiol 2000; 35:1288-940 tested this concept
with forty patients who underwent coronary stent placement less
than six weeks before non-cardiac surgery. They did really badly.
MI in 18%, Major bleeding in 28%, Death in 20%. If the stent was
placed one day prior to surgery, the mortality was 100%. Well,
what about a drug eluting stent, they are the new thing du jour?
Well, drug eluting stents are probably more dangerous. With a
non drug eluting intracoronary stent the coronary endothelium
can cover up the stent in a reasonable period of time (many months).
A drug eluting stent is designed to inhibit endothelial growth.
It is unclear how long it takes to cover the drug eluting stents
to the point where they are safe. Moreover, the perioperative
period is a period of hypercoagulability secondary to tissue trauma
and stress. Studies which demonstrate that it is safe to discontinue
anti-platelet agents after a number of months for non-operative
patients, may not be applicable to surgical patients.
DO
NOT DISCONTINUE PROPHYLACTIC ANTI-PLATELET AGENTS IN PATIENTS
WITH INTRACORONARY STENTS WITHOUT A LOT OF THOUGHT!
It can quickly be lethal secondary
to intra-coronary clot on the stent.
