How long do you wait after coronary stent placement b/4 performing elective surgery?
What do you do with the meds they are on, Plavix, ASA?

Case example:
Healthy 64yo male for knee scope. CAD, good overall exercise tolerance, MEds are plavix, ASA, Toprol XL. Had "drug eluting stent" to circumflex artery 6 months ago. Asymptomatic at this time and b/4 stent placement (found on routine heart W/U).

What are your recommendations?
Do you proceed with the case?
What about his meds?

How long do you wait after coronary stent placement b/4 performing elective surgery?
What do you do with the meds they are on, Plavix, ASA?

Case example:
Healthy 64yo male for knee scope. CAD, good overall exercise tolerance, MEds are plavix, ASA, Toprol XL. Had "drug eluting stent" to circumflex artery 6 months ago. Asymptomatic at this time and b/4 stent placement (found on routine heart W/U).

What are your recommendations?
Do you proceed with the case?
What about his meds?

Proceed to OR - LMA - Sevo/Fentanyl/oxygen/nitrous

Hold Plavix and ASA for 5 days prior to procedure

Toprol XL in a.m. DOS

Proceed to OR - LMA - Sevo/Fentanyl/oxygen/nitrous

Hold Plavix and ASA for 5 days prior to procedure

Toprol XL in a.m. DOS

We generally wait 6 months - agree with Sensei's plan.

However, "Healthy" and CAD with a recent stent don't go in the same sentence. ;)

A cardiology attending I worked with last month who is on top of all the literature told me there really isn't any great evidence for continuing plavix more than 3 months post-stent so I'd have no qualms about holding it for a week or two before an elective procedure if you are say 4-6 months or more out.

after a stent...you wait a minimum of 4 weeks...preferably 6 weeks, after that you can do what ever you want.

4-6 weeks after the stent is placed. If you stop plavix prior to the end of this crucial period, you run into a 25-35% chance of developing stent occlusion.

Otherwise, in your scenario, one week off plavix is sufficient, especially since your patient is six months out. Stopping ASA 3 to 5 days prior to surgery is usually the norm at our institution, with the exception of cases performed by certain services.

It depends on the type of stent used. If it's a bare-metal stent, then 1 month of plavix is enough. If it's a drug-eleuting stent, then most cardiologists will have the patients stay on plavix for 6 months, although a few may be comfortable with temporarily holding plavix for surgery after 3 months post-cath.

In the case mentioned, the patient is already 6 months post DES placement, so should no longer need plavix anyway, unless there's a different reason he should be on plavix....

agree with previous posters. stent has been in 6 months and from what i recall from intern year cards, after 6 months the Plavix can be stopped.

currently asymptomatic with good exercise tolerance, so he should have a green light for the OR. granted, having a recent myocardial perfusion would be a bonus, but not something that should hold up this case.

would stop Plavix 10-14 days before his scope, stop ASA 3-5 days before, continue his metoprolol (including AM of surgery).

If I told you guys that you wait 1 yr for "drug eluting stents" and continue the ASA and the plavix will be continued or discontinued based on the type of surgery, would you say I am crazy? Probably, but the recent recommendations at the Society of Cardiac Anesthesiologists is exactly that.


Check out this article:

Noncardiac surgery in patients with coronary artery stent: what should the anesthesiologist know?

CORONARY artery stents significantly decrease coronary restenosis and abrupt vessel closure as compared to standard coronary balloon angioplasty.1–4 Consequently, they are implanted in most patients requiring percutaneous coronary intervention (PCI).5 One major consideration with coronary stents is their thrombogenicity at the blood-tissue interface which may cause local thrombosis or distal coronary embolization. Those complications are associated with a 50% incidence of acute myocardial infarction (MI) and a 20% mortality rate,6 making prevention of stent thrombosis mandatory in all cases. The most effective antithrombotic strategy involves the administration of aspirin and a thienopyridine (clopidogrel or ticlopidine) for a minimum period of four to six weeks for bare metal stents and several months for drug-eluting stents, until significant re-endothelialization of the stent has occurred. With this approach, stent thrombosis within 30 days of implantation occurs in less than 1% of patients who had an uncomplicated PCI.6

In their most recent guideline update for perioperative cardiovascular evaluation for noncardiac surgery, the American College of Cardiology (ACC) and the American Heart Association (AHA) recommended a delay of at least two weeks and ideally four to six weeks between stent implantation and noncardiac surgery (e.g., four full weeks of dual antiplatelet therapy during stent re-endothelialization and two weeks for the antiplatelet effect to wear off).7 There is no prospective controlled trial to support that recommendation. However, at least two retrospective studies provide convincing arguments for its rationale.8,9 In the first study, of 40 patients undergoing noncardiac surgery less than six weeks after coronary stenting, seven (18%) had an MI, 11 (28%) had major bleeding and eight (20%) died.8 All deaths and MIs, and eight of the 11 bleeding episodes occurred in patients who had surgery less than two weeks after coronary stenting. In the second study, eight (4.0%) of 207 patients who had surgery within two months of coronary stenting suffered an MI, of whom six (2.9%) died.9 All deaths and MIs occurred among the 168 patients who had surgery within six weeks of stent placement. No major adverse event occurred in the 39 patients operated seven to nine weeks after stent placement. Those two studies did not determine whether the acute ischemic complications were due to coronary stenting or to the increased inflammatory and procoagulable state of those patients and the presence of other vulnerable plaques. In addition, they did not test whether postponing of surgery could improve outcome or not. However, they clearly indicate that noncardiac surgery within six weeks of coronary stenting is associated with an increased risk of serious peri-operative cardiac events.

It is difficult to argue against the authors’ second conclusion. To maintain their competence, anesthesiologists must continuously review guidelines related to perioperative care, particularly if they relate to coronary artery disease which largely contributes to perioperative morbidity and mortality. However, it is unclear how Patterson et al. reached their first conclusion. Did they interpret the most frequent anesthesiologists’ answers as the right approach? If that was the case, it would be wrong and maybe presumptuous for anesthesiologists alone to establish a policy on a highly specialized cardiology topic. To have any credibility, any perioperative policy on coronary stenting should involve experienced interventional cardiologists and expert perioperative physicians (e.g., anesthesiologists and intensivists). This is how the ACC/AHA guidelines were developed. It would probably be wiser for Canadian anesthesiology departments to refer to those guidelines or similar ones rather than develop their own.

It is possible that Patterson et al. intended to stimulate Canadian anesthesiology departments to develop a policy based on the existing ACC/AHA guidelines. This would make their first conclusion more acceptable, but not necessarily right for many reasons. First, there is a paucity of information and an absence of controlled studies on the perioperative outcomes of patients with recent coronary stenting. Second, the processes leading to stent thrombosis are complex and multifactorial. They involve the type of stent implanted, its total length, the size of the final lumen diameter and the possibility of persistent dissection at the time of procedure.6 The consideration of all those factors makes it almost impossible to establish guidelines applicable to all patients with coronary stents. Third, the current ACC/AHA perioperative guidelines regarding coronary stents apply only to patients with bare metal stents, not to brachytherapy (e.g., intra-coronary radiation with gamma or beta emitters) or drug-eluting stents.11 Finally, this highly specialized technology evolves rapidly and is constantly challenged by new reports. For example, the four to six weeks’ delay recommended by the ACC/AHA was recently questioned following a case of fatal MI due to stent thrombosis in a patient who underwent lung resection six weeks after the prophylactic implantation of a coronary stent.12 In their report, the authors strongly argued that complete stent re-endothelialization takes up to three months.13 Consequently, they recommended a waiting period of three months between stent implantation and elective surgery, as previously suggested by Chassot et al.14 This discrepancy between the waiting period recommended by Chassot et al. and the ACC/AHA guidelines is only one of the controversies that Canadian anesthesiology departments would face if they established their own policy.

The rapid development of new strategies to prevent in-stent restenosis is another argument against any policy setting a fixed delay between coronary stenting and elective surgery. In-stent restenosis is a phenomenon mainly due to neointimal proliferation. It peaks around the third month and reaches a plateau between the third and sixth month after the procedure. Brachytherapy has been used to treat in-stent restenosis and drug-eluting stents have been proven to prevent it.11 Brachytherapy inhibits the intimal hyperplasia by breaking the cell’s DNA and blocking mitosis. Covered with a polymer and a drug spread over the metal, drug-eluting stents provide the slow release of a substance inhibiting cell proliferation. Sirolimus (an antifungal with potent cell cycle inhibitory effect) and paclitaxel (a compound with potent anti-tumour activity) are the commonly used substances in drug-eluting stent therapy.11 A common effect of brachytherapy and drug-eluting stents is delayed re-endothelialization. Little is known on how brachytherapy or drug-eluting stents should be managed perioperatively. The management may differ considerably depending on the stent structure, its polymer coating and its active pharmacological agent. The clinical importance of delayed re-endothelialization by drug-eluting stents was recently highlighted in a patient who, 12 weeks prior to knee surgery, had simultaneous implantation of a bare metal stent in his right coronary artery (RCA) and two paclitaxel-eluting stents in his left circumflex artery (LCX).15 Two hours after the procedure, the patient developed acute MI. Coronary angiography revealed total occlusion of both drug-eluting stents in the LCX and normal flow in the RCA. Recanalization of the LCX was performed successfully and the patient did well. How long after the implantation of those drug-eluting stents should the patient have waited before that relatively minor surgery? This is another issue that cannot be resolved through a policy setting a fixed waiting period between coronary stenting and surgery.

In summary, the survey by Patterson et al. should alert all anesthesiologists about the risk of major adverse events in surgical patients with recent coronary stents. However, it would be hazardous for Canadian anesthesiology departments to establish on their own a fixed policy on the acceptable delay between coronary stenting and elective surgery. Such a policy could rapidly become obsolete with the risk of denying the appropriate surgery to a specific patient at the appropriate time. It seems wiser for anesthesiologists to adopt a case by case approach with the following precautions. First, in a surgical patient with a history of PCI and coronary stent, determine the date of the procedure, the kind of stent inserted and the possibility of complications during the procedure. Second, consider all patients with a recent stent implantation (e.g., less than three months for bare metal stents and less than one year for brachytherapy or drug-eluting stents) as high-risk and consult an interventional cardiologist. Third, any decision to postpone surgery, continue, modify or discontinue antiplatelet regimes must involve the cardiologist, the surgeon, the anesthesiologist and the intensivist who will balance the risk and benefit of each decision. Finally, if an emergency noncardiac surgery is necessary in a patient with recent coronary stenting, the surgery should preferably be performed in a centre with interventional cardiology care for prompt intervention in case of stent thrombosis. Those precautions are based on the currently available information. Anesthesiologists are encouraged to follow the new developments on coronary stents to provide the best possible care to patients presenting with this condition.

How long do you wait after coronary stent placement b/4 performing elective surgery?
What do you do with the meds they are on, Plavix, ASA?

Case example:
Healthy 64yo male for knee scope. CAD, good overall exercise tolerance, MEds are plavix, ASA, Toprol XL. Had "drug eluting stent" to circumflex artery 6 months ago. Asymptomatic at this time and b/4 stent placement (found on routine heart W/U).

What are your recommendations?
Do you proceed with the case?
What about his meds?

For a knee scope, if the Plavix doesnt bother the surgeon, it doesnt bother me.

These ASA 3 people are the cases I see every day.

Again, a no brainer.

Stable CAD dude.

Midaz 2mg.

To the OR.

Monitors on. Mask on.

Propofol 150mg. Talk with the CRNA/circulator/scrub tech/transporter to make the 30 seconds pass quicker.

Slip the LMA #4 in.

Turn the sevo vaporizer to the left to about 3.

Continue conversation about recent fishing trip in Lake Pontchartrain while you tidy things up. Yep, the specks love the Tsunami lure, huh??

Noy, you know I love you dude.

You da f u kkin g man.

But my mom could do this case.

OK, enough kidding-banter, so I'll get a little scientific for our budding colleagues out there. And even though I've got a dip of Copenhagen in as we speak, I'm gonna spew some cool-sounding sh i t.

Beta blockade in a patient known to have preoperative coronary artery disease is a good thing. Beta blockade reduces morbidity/mortality in this patient population. So the dudes Toprol is a good thing.

The fact that knee-scope-dude has good exercise tolerance is THE MOST important part of Noyac's description. Said description, from an anesthesiologists point of view, means you can proceed pretty-much like you would do with anyone else.

A knee scope is a bread-and-butter case in our profession. Its a gravy case. No fluid shifts. No blood loss.

Its gonna be REALLY HARD to cause anesthesia morbidity on this case, which usually lasts 20-60 minutes.

As an aside, recent literature is showing Plavix's risks may exceed it's benefits.

But thats a whole different potential-thread.

Do you translate these results to pts who have stents in areas other than the coronary arteries - renal or carotid stents?

Also...do you treat these pts differently if you have a stable CAD pt, but who is on a ca channel blocker or nitrate? Do these folks have a greater incidence of transient coronary spasm which could be potientated by drugs or procedures used by anesthesia or the surgery itself? The last data I read was abrupt closure due to spasm was about 4%, altho I'm not sure how far out from stenting the data was reliable.

I'm not sure if these subsets have been studied, but I'd be curious to know.

In summary, the survey by Patterson et al. should alert all anesthesiologists about the risk of major adverse events in surgical patients with recent coronary stents. However, it would be hazardous for Canadian anesthesiology departments to establish on their own a fixed policy on the acceptable delay between coronary stenting and elective surgery. Such a policy could rapidly become obsolete with the risk of denying the appropriate surgery to a specific patient at the appropriate time. It seems wiser for anesthesiologists to adopt a case by case approach with the following precautions. First, in a surgical patient with a history of PCI and coronary stent, determine the date of the procedure, the kind of stent inserted and the possibility of complications during the procedure. Second, consider all patients with a recent stent implantation (e.g., less than three months for bare metal stents and less than one year for brachytherapy or drug-eluting stents) as high-risk and consult an interventional cardiologist. Third, any decision to postpone surgery, continue, modify or discontinue antiplatelet regimes must involve the cardiologist, the surgeon, the anesthesiologist and the intensivist who will balance the risk and benefit of each decision. Finally, if an emergency noncardiac surgery is necessary in a patient with recent coronary stenting, the surgery should preferably be performed in a centre with interventional cardiology care for prompt intervention in case of stent thrombosis. Those precautions are based on the currently available information. Anesthesiologists are encouraged to follow the new developments on coronary stents to provide the best possible care to patients presenting with this condition.

Interesting article, but I couldn't figure out how the author chose to recommend a one year waiting period post DES placement -- the studies that were mentioned only looked at surgeries 3 months post cath... unless I'm missing something?

I definitely agree, though, that any decision to stop or hold plavix/ASA in a post PCI patient should involve the patient's cardiologist.

Not only these arthurs are recommending waiting 1yr but the Society of Cardiovascular Anesthesiologists (SCA) are as well.

Jet, I know that this is the easiest case in the world. But the article and the SCA recommend waiting 1 yr due to the increased risk of clotting off the stent. With the DES (drup eluting stents) the impregnated stent prevents intimal lining from occuring in the stents therefore, preventing ISS (In-Stent Stenosis). With this exposed stent lining and holding the plavix and ASA (I know we don't need to hold them for this case) the risk of clotting off the stent and resultant MI is very high. THe article called it a HIGH RISK pt. Also the simple little knee scope as with any tyoe of surgery will activate the clotting (coagulation) cascade which will lead to increased risk.

Here is an article talking about stents from SCA: http://www.scahq.org/sca3/newsletters/2003dec/drug1.shtml

Regional anyone?

Regional anyone?

Recommendations are to keep the plavix and asa going therefore, I wouldn't do regional. Plus regional does not change the fact that the coagulation cascade has been activated during surgery. Remember, surgical insult - local inflamation - mediators - fibrin - platelets - etc.

Regional anyone?

That is so 80's-ish.

Even if you discontinue the Plavix for a week before, I would still want to check a Plavix teg. The platelets can remain completely inhibited for a significant amount of time even off the drug. I would guess an ortho surgeon wouldn't think about it, but the potential complications of bleeding even in a routine surgery could be bad.

I may be wrong, but I think our hearts do continue plavix for a year, both the stents and the bypass patients.

That is so 80's-ish.

No, Friend,

Thats two-thousand-six.

Accept it.

You are deft.

Guide the Tuohy instead of the Miller 2.

No, Friend,

Thats two-thousand-six.

Accept it.

You are deft.

Guide the Tuohy instead of the Miller 2.

No, I mean to protect the heart by doing REgional.....REgional anesthesia provides NO cardiovascular benefit....that horse is dead and buried.

Now, the other benefits....unfortunately...I am unable to argue effectively....you know...those soft, kind and gentler type benefits....

No, Friend,

Thats two-thousand-six.

Accept it.

You are deft.

Guide the Tuohy instead of the Miller 2.

and I use a Miller 3

...you know...those soft, kind and gentler type benefits....

HAHAHAHAHHAHAHHAHAHAHAHAHAHAHHA

you made me laugh at 6 o'clock in the morning.

Even if you discontinue the Plavix for a week before, I would still want to check a Plavix teg. The platelets can remain completely inhibited for a significant amount of time even off the drug. I would guess an ortho surgeon wouldn't think about it, but the potential complications of bleeding even in a routine surgery could be bad.

I may be wrong, but I think our hearts do continue plavix for a year, both the stents and the bypass patients.I'll bet most hospitals or anesthesia departments outside academic or cardiac centers don't have TEG capability.

I'll bet most hospitals or anesthesia departments outside academic or cardiac centers don't have TEG capability.

We have it but I could care less.

We have it but I could care less.

Why do you say that? I guess it is a concern for me because I've seen the bad results, more than once, and had a patient have to go back for emergency surgery from uncontrollable post op bleeding. Granted, it was a major surgery, and not a knee scope, but the potential is there right?

My understanding of the Teg is that it tells what percentage of the platelets are bound to the drug. If all your platelets are bound to the drug, then you don't have any free to form a clot if necessary. If you have a teg of 100%, we typically give platelets and FFP, but often when we repeat another teg, it will still be 100% inhibited because there was still so much drug in the system, the platelets that were transfused binded to the free drug in the system.

Is your comment that you don't care in this particular situation because it's a low risk procedure, so that you don't care in general to know what a patient's teg is if they've been on a drug like ASA or plavix?

Why do you say that? I guess it is a concern for me because I've seen the bad results, more than once, and had a patient have to go back for emergency surgery from uncontrollable post op bleeding. Granted, it was a major surgery, and not a knee scope, but the potential is there right?

My understanding of the Teg is that it tells what percentage of the platelets are bound to the drug. If all your platelets are bound to the drug, then you don't have any free to form a clot if necessary. If you have a teg of 100%, we typically give platelets and FFP, but often when we repeat another teg, it will still be 100% inhibited because there was still so much drug in the system, the platelets that were transfused binded to the free drug in the system.

Is your comment that you don't care in this particular situation because it's a low risk procedure, so that you don't care in general to know what a patient's teg is if they've been on a drug like ASA or plavix?

TEG...another expensive toy that give information that has not been shown to improve outcomes.

TEG...another expensive toy that give information that has not been shown to improve outcomes.


My point exactly. I have not found it to be a benefit.

So with this new information are any of you guys planning on changing your practice? Will you hold off elective surgery on these pts with drug eluting stents for 1 year? Or will you continue with the current practice?