Case Scenario

[h2oriderz]

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67 yr old male scheduled for femoral endarterectomy for lower extremity claudication. The usual history of HTN, HLD, DM, no MI but an obvious vasculopath etc. Pt was scheduled for the surgery a couple weeks ago but ended up going to the cath lab instead where he received 3 DES's. It's now 18 days out from the cath lab and pt is on the standard DAPT of ASA/Plavix .Surgeon is aware of the timeframe, says the cardiologist said the pt is fine to go for surgery and he wants to go now. The cardiologist is down the hall in the interventional suite. How do you proceed?

PS -- Don't forget that your hospital is trying to get this surgeon to bring more of his cases over to your OR, so don't piss him off.

Discuss...

 

[TrustMe]

Give him his ASA and plavix that morning. Give some IV metoprolol with induction. Put in an ETT and a-line and keep his BP up and HR down.

You could defer the case and wait until he has rest pain and a compromised limb but that seems a little excessive. He has a leg with compromised perfusion that needs fixed so you should help him with that.

 

[aredoubleyou]

67 yr old male scheduled for femoral endarterectomy for lower extremity claudication. The usual history of HTN, HLD, DM, no MI but an obvious vasculopath etc. Pt was scheduled for the surgery a couple weeks ago but ended up going to the cath lab instead where he received 3 DES's. It's now 18 days out from the cath lab and pt is on the standard DAPT of ASA/Plavix .Surgeon is aware of the timeframe, says the cardiologist said the pt is fine to go for surgery and he wants to go now. The cardiologist is down the hall in the interventional suite. How do you proceed?

PS -- Don't forget that your hospital is trying to get this surgeon to bring more of his cases over to your OR, so don't piss him off.

Discuss...

Look at echo, assuming function descent, prop, sux, tube,.. light on the prop. Bad function, c/line, a-line, press him with some norepi. Not the boards answer, but tried and true. I'd rather be dealing with plavix than non-revascularized heart, so altogether I wouldn't make a big fuss about it.

 

[Idiopathic]

never mind my question was stupid given hes not coming off plavix

 

[Libertas]

There is pretty strong evidence to give at least 6 months of uninterrupted DAPT s/p DES. Regardless of what the cardiologist says, I do not think it would be safe to go to elective surgery 18 days out from stenting, the risk of coronary event with holding plavix would be quite high. I think you'd be hard pressed to call seemingly stable claudication an emergent case? No regional on plavix.

 

[pgg]

67 yr old male scheduled for femoral endarterectomy for lower extremity claudication. The usual history of HTN, HLD, DM, no MI but an obvious vasculopath etc. Pt was scheduled for the surgery a couple weeks ago but ended up going to the cath lab instead where he received 3 DES's. It's now 18 days out from the cath lab and pt is on the standard DAPT of ASA/Plavix .Surgeon is aware of the timeframe, says the cardiologist said the pt is fine to go for surgery and he wants to go now. The cardiologist is down the hall in the interventional suite. How do you proceed?

PS -- Don't forget that your hospital is trying to get this surgeon to bring more of his cases over to your OR, so don't piss him off.

Discuss...

Why did he unexpectedly go to the cath lab instead of surgery 18 days ago? No MI per your history, but getting diverted from the OR to the cath lab on the day of your surgery is about as red as flags get.

Is this case really elective? How symptomatic is the claudication? What does the surgeon have to say about the urgency of this case? If the patient has constant pain and life-altering functional limitations, you can make a r/b argument for doing this case now, but I'd feel the need to document something showing that a 6 month wait is not acceptable.

Did the cardiologist document anything concerning this surgery 18 days out? The fact that the surgeon says the cardiologist is cool with it means nothing to me. If he's really just down the hall, I'd take the time to talk to him, if for no other reason than my own education because a cardiologist allegedly OK'ing elective surgery <3wks after stent placement is odd. Also (to satisfy my curiosity more than anything else), I'd ask him why, if he knew the patient was going to have noncardiac surgery soon, he used DES instead of BMS.

A great way to piss off a surgeon is to kill his patients via malpractice.

 

[dhb]

Cardio probably OK'ed it if anti-agregation medication isn't discontinued.

 

[pgg]

Cardio probably OK'ed it if anti-agregation medication isn't discontinued.

Continuing the ASA/Plavix this soon after stent placement ought to be a given. I still wouldn't do an elective vascular case 18 days after DES placement.

 

[fakin' the funk]

Don't forget that your hospital is trying to get this surgeon to bring more of his cases over to your OR, so don't piss him off.

Your hospital should try to recruit smarter surgeons.

And, smarter cardiologists (for putting in a DES instead of a BMS).

Doing this case 18 days after THREE stents is not supported by ANY guidelines. Nor does it make a priori sense, nor is the case urgent, etc. This is major noncardiac surgery and regardless of the revascularization and dual antiplatelet therapy, there is going to be massive systemic inflammation after this surgery. Y'know, the kind that causes clots to form in new stents.

Even if you make the argument that the case can't wait 6 months, ANY amount of waiting is better than 18 days.

 

[urge]

Pent sux tube. Ship him to the cath lab if he looks funny at you.

 

[h2oriderz]

Give him his ASA and plavix that morning. Give some IV metoprolol with induction. Put in an ETT and a-line and keep his BP up and HR down.

You could defer the case and wait until he has rest pain and a compromised limb but that seems a little excessive. He has a leg with compromised perfusion that needs fixed so you should help him with that.

With the possibility of having 3 occluded stents post-op, he will have other areas in the body with compromised perfusion. Are you ok with taking that risk?

There is pretty strong evidence to give at least 6 months of uninterrupted DAPT s/p DES. Regardless of what the cardiologist says, I do not think it would be safe to go to elective surgery 18 days out from stenting, the risk of coronary event with holding plavix would be quite high. I think you'd be hard pressed to call seemingly stable claudication an emergent case? No regional on plavix.

No interuption of DAPT, he is taking both medications. Definitely not emergent, surgeon would not even commit to it being urgent.

Why did he unexpectedly go to the cath lab instead of surgery 18 days ago? No MI per your history, but getting diverted from the OR to the cath lab on the day of your surgery is about as red as flags get.

This case happened a few months back, but I don't think he was in preop for surgery and then taken to the cath lab. I think he had a positive preop stress test and was then sent to the cath lab.

Is this case really elective? How symptomatic is the claudication? What does the surgeon have to say about the urgency of this case?

I threw him a bone and asked if he would at least say that it was an urgent case, he declined to take my lifeline.

The fact that the surgeon says the cardiologist is cool with it means nothing to me.

You're damn right it means nothing.

If he's really just down the hall, I'd take the time to talk to him

I made the trip down there and he felt that since pt is on DAPT and would receive heparin intraop that he would be fine.

I'd ask him why, if he knew the patient was going to have noncardiac surgery soon, he used DES instead of BMS.

This is the million dollar question.

Continuing the ASA/Plavix this soon after stent placement ought to be a given. I still wouldn't do an elective vascular case 18 days after DES placement.[/

Bingo.

Your hospital should try to recruit smarter surgeons.

And, smarter cardiologists (for putting in a DES instead of a BMS).

Doing this case 18 days after THREE stents is not supported by ANY guidelines. Nor does it make a priori sense, nor is the case urgent, etc. This is major noncardiac surgery and regardless of the revascularization and dual antiplatelet therapy, there is going to be massive systemic inflammation after this surgery. Y'know, the kind that causes clots to form in new stents.

Even if you make the argument that the case can't wait 6 months, ANY amount of waiting is better than 18 days.

Well that about sums it up perfectly for me.

 

[Mman]

is the recommendation still for no non-urgent surgeries within 12 months after placement of a DES?

Not sure why anybody would want to roll the dice on freshly placed DES (x 3!!?!?!) for what is essentially a completely elective case.

 

[BLADEMDA]

is the recommendation still for no non-urgent surgeries within 12 months after placement of a DES?

Not sure why anybody would want to roll the dice on freshly placed DES (x 3!!?!?!) for what is essentially a completely elective case.

Sometimes these cases are not "elective" at all and this is why a discussion with the surgeon is in order. We do very sick patients at my hospital some of whom are far worse than this patient.

If the Leg is in jeopardy (which is often the case) then the most you could wait would be a few extra days which wouldn't change much. Suprisingly, very few of these Vasculopaths actually die in the following few weeks after these surgeries. Many present again for open Fem Pop Bypasses.

As long as the Vascular Surgeon is aware of the Drug Eluting Stents and thinks this procedure can't wait several months then I would proceed. These days very few patients stop their Plavix or Asa for these procedures.

I like Ketafol for these cases (TIVA) but an LMA works fine as well. Again, as long as a discussion occurs with the all members of the team with documentation on the record I would do this case.

 

[BLADEMDA]

In the absence of universally accepted protocols for management of patients who present for NCS following recent stent placement, it is necessary for collaborative decision making to take place between the patient, internist, surgeon, anesthesiologist, and cardiologist. We strongly encourage this multidisciplinary discussion to include the type and timing of stent placed, the importance of the type of surgery being considered, the management of perioperative antiplatelet therapy, and the choice of facility at which to perform the surgery. If surgery needs to be performed in patients with recent stent placement, if possible, it should take place where a 24-hour interventional cardiologist is available, as emergent PCI remains the best treatment option.2


Acknowledgments


The authors wish to thank John G. T. Augoustides, MD, FASE, FAHA (University of Pennsylvania Medical Center, Philadelphia) for sharing his expert opinion on this matter.

Dr. Greenberg is an associate professor, Dr. Matten is an instructor, Dr. Murphy is an associate professor, and Dr. Vender is a professor, all at the Northwestern University Feinberg School of Medicine, NorthShore University Healthsystem, Evanston, IL.

 

[BLADEMDA]

http://www.brighamandwomens.org/Dep.../Documents/DES_and_Elective_Surgery_Jan11.pdf


Take at look at the Brigham and Women's Protocol

 

[h2oriderz]

Sometimes these cases are not "elective" at all and this is why a discussion with the surgeon is in order. We do very sick patients at my hospital some of whom are far worse than this patient.

If the Leg is in jeopardy (which is often the case) then the most you could wait would be a few extra days which wouldn't change much. Suprisingly, very few of these Vasculopaths actually die in the following few weeks after these surgeries. Many present again for open Fem Pop Bypasses.

As long as the Vascular Surgeon is aware of the Drug Eluting Stents and thinks this procedure can't wait several months then I would proceed. These days very few patients stop their Plavix or Asa for these procedures.

I like Ketafol for these cases (TIVA) but an LMA works fine as well. Again, as long as a discussion occurs with the all members of the team with documentation on the record I would do this case.

Unfortunately the surgeon and I were not on the same page. He felt that the patient was not at an increased risk for a perioperative cardiac event, likely because he had the cardiologist telling him that the patient would be fine for surgery. If the surgeon would have said "I think this is case is urgent , and waiting could prove to be catastrophic to the pt's leg" then we would have been in a totally different situation. This is an intermediate risk case and if it were designated as urgent, then I would have proceeded with the DAPT on board and hope for the best -- most of the time the outcome should be fine. But this was elective, and I was unwilling to accept the risk.

Blade, would you have done the case knowing that it was elective per the surgeon? And the surgeon telling the pt that he was at no increased risk whatsoever?

 

[BLADEMDA]

is the recommendation still for no non-urgent surgeries within 12 months after placement of a DES?

Not sure why anybody would want to roll the dice on freshly placed DES (x 3!!?!?!) for what is essentially a completely elective case.

I absolutely agree that the earliest an elective case should be allowed to proceed with a DES is 6 months and that is only if the Plavix and ASA are continued perioperatively. If the Plavix is discontinued then wait 12 months.

Second, the Cardiology literature is clear that if surgery will be required within the next 30-60 days then a Bare Metal Stent should be placed and a DES should be avoided.

The case described here shows a disregard for standard protocol and published literature by the Cardiologist and the Vascular Surgeon. I would discuss the medicolegal risk of proceeding with this case in private with the Vascular Surgeon and inform him/her I will only proceed if the case is Urgent in nature. I would document that discussion on my preop note.

The real MORAL question of the day is does the patient have a right to know about his/her increased risk of DEATH by proceeding with this intervention so soon after DES placement. IMHO, I believe INFORMED CONSENT requires this discussion with the patient after talking with the vascular surgeon. This must be handled delicately and is a tough situation for a "junior" member of the Attending staff (i.e., get a senior partner involved).

 

[h2oriderz]

I absolutely agree that the earliest an elective case should be allowed to proceed with a DES is 6 months and that is only if the Plavix and ASA are continued perioperatively. If the Plavix is discontinued then wait 12 months.

Second, the Cardiology literature is clear that if surgery will be required within the next 30-60 days then a Bare Metal Stent should be placed and a DES should be avoided.

The case described here shows a disregard for standard protocol and published literature by the Cardiologist and the Vascular Surgeon. I would discuss the medicolegal risk of proceeding with this case in private with the Vascular Surgeon and inform him/her I will only proceed if the case is Urgent in nature. I would document that discussion on my preop note.

The real MORAL question of the day is does the patient have a right to know about his/her increased risk of DEATH by proceeding with this intervention so soon after DES placement. IMHO, I believe INFORMED CONSENT requires this discussion with the patient after talking with the vascular surgeon. This must be handled delicately and is a tough situation for a "junior" member of the Attending staff (i.e., get a senior partner involved).

I agree 100% with everything you wrote here. I was a little shocked that I was the last line of defense for this pt and that neither the surgeon nor the cardiologist thought that there was any issue. The evidence is so clear, I was baffled. And yes, being a junior attending did not help. I was courteous, but fairly direct about the perioperative risks with regards to the DES's. I confronted the cardiologist with the surgeon by my side -- he said that he understood why I did not want to proceed with the case (perhaps he needed to follow his own governing body's guidelines). I did step the case up to someone more senior than I, and he 100% backed me and my decision to cancel the case. I was extremely frank with the patient about the increased likelihood of a periop cardiac event, he absolutely had a right to know. I did not win any points for the hospital or myself with this particular surgeon, he's still pissed about it from what I understand. It was a good experience for me to have early on in my career. Sometimes you need to take a stand for your patient and your profession.

 

[GoldnLead]

I agree 100% with everything you wrote here. I was a little shocked that I was the last line of defense for this pt and that neither the surgeon nor the cardiologist thought that there was any issue. The evidence is so clear, I was baffled. And yes, being a junior attending did not help. I was courteous, but fairly direct about the perioperative risks with regards to the DES's. I confronted the cardiologist with the surgeon by my side -- he said that he understood why I did not want to proceed with the case (perhaps he needed to follow his own governing body's guidelines). I did step the case up to someone more senior than I, and he 100% backed me and my decision to cancel the case. I was extremely frank with the patient about the increased likelihood of a periop cardiac event, he absolutely had a right to know. I did not win any points for the hospital or myself with this particular surgeon, he's still pissed about it from what I understand. It was a good experience for me to have early on in my career. Sometimes you need to take a stand for your patient and your profession.

You did the right thing here. This is an elective case. The risk of a period MI after such a recent DES placement is too high.

 

[Jay K]

Nice case, thank you for sharing.

 

[Arch Guillotti]

c/line, a-line

I understand where you are coming from but there is no way I would do a central line and doubt an aline for this case.

 

[Arch Guillotti]

Sometimes these cases are not "elective" at all and this is why a discussion with the surgeon is in order. We do very sick patients at my hospital some of whom are far worse than this patient.

If the Leg is in jeopardy (which is often the case) then the most you could wait would be a few extra days which wouldn't change much. Suprisingly, very few of these Vasculopaths actually die in the following few weeks after these surgeries. Many present again for open Fem Pop Bypasses.

As long as the Vascular Surgeon is aware of the Drug Eluting Stents and thinks this procedure can't wait several months then I would proceed. These days very few patients stop their Plavix or Asa for these procedures.

I like Ketafol for these cases (TIVA) but an LMA works fine as well. Again, as long as a discussion occurs with the all members of the team with documentation on the record I would do this case.

Agree with all of this except I would lean towards ETT. I like to discuss these type of issues with the surgeon in front of the patient and family if possible.

 

[Arch Guillotti]

I absolutely agree that the earliest an elective case should be allowed to proceed with a DES is 6 months and that is only if the Plavix and ASA are continued perioperatively. If the Plavix is discontinued then wait 12 months.

Second, the Cardiology literature is clear that if surgery will be required within the next 30-60 days then a Bare Metal Stent should be placed and a DES should be avoided.

The case described here shows a disregard for standard protocol and published literature by the Cardiologist and the Vascular Surgeon. I would discuss the medicolegal risk of proceeding with this case in private with the Vascular Surgeon and inform him/her I will only proceed if the case is Urgent in nature. I would document that discussion on my preop note.

The real MORAL question of the day is does the patient have a right to know about his/her increased risk of DEATH by proceeding with this intervention so soon after DES placement. IMHO, I believe INFORMED CONSENT requires this discussion with the patient after talking with the vascular surgeon. This must be handled delicately and is a tough situation for a "junior" member of the Attending staff (i.e., get a senior partner involved).

Again, agree with pretty much everything BLADE has written. Sometimes I try and catch the surgeon in the lounge to have a chat and to be upfront about the risks. Sometimes they don't "get it" but that is life. I don't always document everything because I am so busy and can get sidetracked with other cases. It is tough being "junior" staff sometimes. Make a good impression from the get-go, be reasonable, have face to face conversations with surgeons when necessary and you will lose the "junior" moniker soon.

 

[Arch Guillotti]

I agree 100% with everything you wrote here. I was a little shocked that I was the last line of defense for this pt and that neither the surgeon nor the cardiologist thought that there was any issue. The evidence is so clear, I was baffled. And yes, being a junior attending did not help. I was courteous, but fairly direct about the perioperative risks with regards to the DES's. I confronted the cardiologist with the surgeon by my side -- he said that he understood why I did not want to proceed with the case (perhaps he needed to follow his own governing body's guidelines). I did step the case up to someone more senior than I, and he 100% backed me and my decision to cancel the case. I was extremely frank with the patient about the increased likelihood of a periop cardiac event, he absolutely had a right to know. I did not win any points for the hospital or myself with this particular surgeon, he's still pissed about it from what I understand. It was a good experience for me to have early on in my career. Sometimes you need to take a stand for your patient and your profession.

Good for you. I have told a stupid surgeon to shove it where the sun doesn't shine a couple of times (very politically correct of course!). If you have solid ground to stand on I wouldn't sweat it one bit. If your decisions are based on solid ground you will gain nothing but respect.

 

[Arch Guillotti]

Thank goodness your senior partner backed you. I think it is very important for the members of a practice to support each other.

 

[nap$ter]

I agree 100% with everything you wrote here. I was a little shocked that I was the last line of defense for this pt and that neither the surgeon nor the cardiologist thought that there was any issue. The evidence is so clear, I was baffled. And yes, being a junior attending did not help. I was courteous, but fairly direct about the perioperative risks with regards to the DES's. I confronted the cardiologist with the surgeon by my side -- he said that he understood why I did not want to proceed with the case (perhaps he needed to follow his own governing body's guidelines). I did step the case up to someone more senior than I, and he 100% backed me and my decision to cancel the case. I was extremely frank with the patient about the increased likelihood of a periop cardiac event, he absolutely had a right to know. I did not win any points for the hospital or myself with this particular surgeon, he's still pissed about it from what I understand. It was a good experience for me to have early on in my career. Sometimes you need to take a stand for your patient and your profession.

nicely done

 

[aredoubleyou]

I understand where you are coming from but there is no way I would do a central line and doubt an aline for this case.

Yea, I suppose we are all overly influenced by our past experiences in different ways...significant systolic dysfunction with vascular, my threshold is low.

 

[DrBeaker]

This is one of those issues that really grinds my gears. OP, solid work on this case, I enjoyed the read and discussion. Thanks.

 

[excalibur]

Real world discussion with this patient now...

"Well when can I have my surgery, then, Doc?"
-In 6 months

"6 MONTHS!!! Are you kidding? I can barely walk 3 blocks before I have to sit down from the pain!"
-I hear what you are saying and I am very sorry about your current discomfort and the fact that you have to wait 6 months to have this operation. This surgery, however, is still considered an elective surgery and since you had cardiac stents just put in, recommendations are that patients wait 6 months for elective surgeries to minimize the risk of your coronary arteries occluding and causing a heart attack"

"Well what if the pain starts getting worse?? What do I do then?"
-If the pain starts getting worse, or if you begin having pain at rest, or you notice new symptoms like skin color changes or coolness in your foot, come to the hospital for an immediate re-evaluation.

"OK, but would that change anything? I thought you said I couldn't have the surgery for 6 months. What happens if I start having those symptoms you mentioned one month from now"
-You would need to come for a re-evaluation because based on your new presenting symptoms and physical exam, it is possible that your disease process could have progressed quickly and significantly deeming a surgical bypass more urgent in nature, and if we felt your leg symptoms posed a greater risk than your current risk of possible MI, we would proceed with surgery at that time.

"So you are telling me the "PLAN" (pt actually uses finger quotes) is that I go on living with this terrible pain rendering from walking any appreciable distance for 6 more months unless of course I develop new symptoms indicative of COMPLETE occlusion of blood supply during that period?!?!
-Um...yes
----------------------------------------------------------------------------
Excalibur here. I feel all management in the OP's case was on the money, but I just wanted to illustrate the real world discussion that has to be had with this patient. Is this the best we can do for him now? I guess it is.

What happens if he comes back 3 weeks later to vascular surgeon's office in tears. He states the constant pain is weighing on him too much. The thought of waiting 5 more months is causing him much despair. He tells the surgeon that prior to his original clinic visit, he experienced the claudication symptoms for only two weeks, and that was unbearable which prompted him to seek medical advice. His physical symptoms have not changed, but he is totally enervated (my word of the day). The case remains nonurgent. The patient states he understands it remains an elective case, but inquires about his actual MI/death risk. "I mean, Doc, are we talking 50/50 here?" -No, No. I am fairly positive the MI risk is not that high. I am most certain it's still a significantly small risk, but it is increased in you as compared to a patient with no CAD particularly as you just required stent placement. If you are actually wanting percentages, I would have to do some research and get back to you with some statistics. "OK. Well say you do that. Say I hear that there is uh a let's say 2% risk of MI or death in my scenario as best as you can tell. What if I then say that I accept that risk, and I still want to proceed with surgery because the current pain is physically and emotionally unbearable. Could we do the surgery then? Could we do the surgery if I sign consent acknowledging that I have been informed of my statistical possibility of MI/death?

???????????????

What's your answer here? Do you say yes now???? Yes now to this nonurgent case because patient has been well informed of the risks, understands them, accepts the risk, and the patient has a reasonable viewpoint on why he wants it done--evrytime he walks he is in intense pain. He says he can't function in day to day living in this state.

Now those that said they would do it now given the circumstances that are now presented, my question is now...why yes now and no 18 days after DES stent placement x 3. Is there that much of a difference between 18 days post DES stent placement and 49 days post DES stent placement? If you feel there is a safer window 49 days after stent placement as compared to 18 days after stent placement and you would be willing to do case, I ask..,would you then initially tell pt after canceling his case that if he comes back in 3 weeks with a full understanding of his risks that you would do his case? No you say? Why not? If he came on his own 3 weeks after his surgery cancellation super depressed stating his case and you felt it was reasonable to do the case, why not just tell the patient up front that you will do it in 3 weeks?

For those that are screaming "It's an elective case!! He needs to wait!" Yes it is an elective case, but think about this. What if every time YOU walked you could only go a few blocks before having to rest because of pain? How long do you think you could deal with that? What if every time you ate, sat down, or talked, you experienced intense pain, and there was an elective surgery that could fix it? How long could you experience intense pain with eating before begging for surgery?

 

[EdPierce]

give him a solid dose of percocet, see if hes still complaining of pain in a week, hell probably never want to get the surgery and just use the pills forever

 

[VentdependenT]

Real world discussion with this patient now...

"Well when can I have my surgery, then, Doc?"
-In 6 months

"6 MONTHS!!! Are you kidding? I can barely walk 3 blocks before I have to sit down from the pain!"
-I hear what you are saying and I am very sorry about your current discomfort and the fact that you have to wait 6 months to have this operation. This surgery, however, is still considered an elective surgery and since you had cardiac stents just put in, recommendations are that patients wait 6 months for elective surgeries to minimize the risk of your coronary arteries occluding and causing a heart attack"

"Well what if the pain starts getting worse?? What do I do then?"
-If the pain starts getting worse, or if you begin having pain at rest, or you notice new symptoms like skin color changes or coolness in your foot, come to the hospital for an immediate re-evaluation.

"OK, but would that change anything? I thought you said I couldn't have the surgery for 6 months. What happens if I start having those symptoms you mentioned one month from now"
-You would need to come for a re-evaluation because based on your new presenting symptoms and physical exam, it is possible that your disease process could have progressed quickly and significantly deeming a surgical bypass more urgent in nature, and if we felt your leg symptoms posed a greater risk than your current risk of possible MI, we would proceed with surgery at that time.

"So you are telling me the "PLAN" (pt actually uses finger quotes) is that I go on living with this terrible pain rendering from walking any appreciable distance for 6 more months unless of course I develop new symptoms indicative of COMPLETE occlusion of blood supply during that period?!?!
-Um...yes
----------------------------------------------------------------------------
Excalibur here. I feel all management in the OP's case was on the money, but I just wanted to illustrate the real world discussion that has to be had with this patient. Is this the best we can do for him now? I guess it is.

What happens if he comes back 3 weeks later to vascular surgeon's office in tears. He states the constant pain is weighing on him too much. The thought of waiting 5 more months is causing him much despair. He tells the surgeon that prior to his original clinic visit, he experienced the claudication symptoms for only two weeks, and that was unbearable which prompted him to seek medical advice. His physical symptoms have not changed, but he is totally enervated (my word of the day). The case remains nonurgent. The patient states he understands it remains an elective case, but inquires about his actual MI/death risk. "I mean, Doc, are we talking 50/50 here?" -No, No. I am fairly positive the MI risk is not that high. I am most certain it's still a significantly small risk, but it is increased in you as compared to a patient with no CAD particularly as you just required stent placement. If you are actually wanting percentages, I would have to do some research and get back to you with some statistics. "OK. Well say you do that. Say I hear that there is uh a let's say 2% risk of MI or death in my scenario as best as you can tell. What if I then say that I accept that risk, and I still want to proceed with surgery because the current pain is physically and emotionally unbearable. Could we do the surgery then? Could we do the surgery if I sign consent acknowledging that I have been informed of my statistical possibility of MI/death?

???????????????

What's your answer here? Do you say yes now???? Yes now to this nonurgent case because patient has been well informed of the risks, understands them, accepts the risk, and the patient has a reasonable viewpoint on why he wants it done--evrytime he walks he is in intense pain. He says he can't function in day to day living in this state.

Now those that said they would do it now given the circumstances that are now presented, my question is now...why yes now and no 18 days after DES stent placement x 3. Is there that much of a difference between 18 days post DES stent placement and 49 days post DES stent placement? If you feel there is a safer window 49 days after stent placement as compared to 18 days after stent placement and you would be willing to do case, I ask..,would you then initially tell pt after canceling his case that if he comes back in 3 weeks with a full understanding of his risks that you would do his case? No you say? Why not? If he came on his own 3 weeks after his surgery cancellation super depressed stating his case and you felt it was reasonable to do the case, why not just tell the patient up front that you will do it in 3 weeks?

For those that are screaming "It's an elective case!! He needs to wait!" Yes it is an elective case, but think about this. What if every time YOU walked you could only go a few blocks before having to rest because of pain? How long do you think you could deal with that? What if every time you ate, sat down, or talked, you experienced intense pain, and there was an elective surgery that could fix it? How long could you experience intense pain with eating before begging for surgery?

Claudication doesnt equal limb threatening lack of arterial flow. Actually claudication is NOT AN INDICATION for revascularization. Limb threatening ABI's are. By the way, how much further can a pt with severe PAD and all its associated comorbidities walk s/p revascularization before having pain? I submit to you, not further compared to medical therapy and an exercise regimen...yup. IT DOESNT WORK for claudication.

If the foot turns blue the case is no longer elective but emergent, to the OR. Not to court.

Anything else?

 

[Orin]

It's my understanding the risk to the patient is greatest in the first 6 weeks regardless of stent type, with the greatest post-operative risk being in the week following surgery. If the patient felt comfortable taking a 10 - 20% risk of cardiac event or death, signed his name to a consent detailing his increasing risks which was witnessed in writing by his next of kin, the surgeon/cardiologist agreed to close inpatient cardiac monitoring for 1 week postoperatively, should we do the surgery?

Is our adherence to guidelines best for this specific patient or are we just reducing our liability by following them?

 

[BLADEMDA]

&#9726;The best evidence of the risk of cardiovascular events in patients who have received an intracoronary stent and who are undergoing noncardiac surgery come from a cohort study of 8116 patients who underwent intermediate-to-high-risk elective noncardiac surgery in Ontario, Canada and received coronary stents within 10 years before surgery [20]. Of these, 34 percent underwent PCI within two years before surgery and DES were used in 33 percent. Outcomes were analyzed by stent type and time from surgery and were compared to 341,550 surgical patients who had not received PCI. While the rates of preoperative platelet P2Y12 receptor blocker were assessed (use varied between 37 and 90 percent depending on the type of stent used and the time interval between PCI and surgery), analyses were not performed based whether the drug was discontinued or not. The primary outcome was 30-day composite of mortality, readmission for acute coronary syndrome, or repeat revascularization


•For the 8116 surgical patients who underwent PCI within 10 years, the primary outcome occurred in 2.1 percent. This rate was comparable to that of intermediate risk individuals who had never received PCI. Intermediate risk was defined using the Revised Cardiac Risk Index [19]. (See "Estimation of cardiac risk prior to noncardiac surgery", section on 'Revised cardiac risk index'.)
•When the interval between stent placement and surgery was less than 45 days, the event rates for BMS and DES were very high at 6.7 and 20.0 percent respectively. Comparing these patients operated on during this time interval to those whose surgery was at least two years after PCI, the adjusted odds ratios [OR] for 30-day events 2.35, 95% CI 0.98-5.64 and 11.58, 95% CI 4.08-32.80, respectively.
•When the interval was 45 to 180 days, the event rate for BMS and DES were 2.6 and approximately 4 percent, respectively. The adjusted OR were 1.06, 95% CI 0.58-1.92 and 1.71, 95% CI 0.73-4.01, respectively.
•for DES When the interval was 181 to 365 days, the event rate s 1.2 percent (adjusted OR 0.64, 95% CI 0.20-2.04). Surprisingly, the event rate for BMS increased to about 3.5 percent during this time period, perhaps due to an increased rate of restenosis with BMS

 

[BLADEMDA]

Elective noncardiac surgery in stented patients — In order to minimize adverse cardiovascular events, we suggest that elective noncardiac surgery be deferred until after the minimal recommended duration of dual antiplatelet therapy (DAT) for each type of stent. For patients treated with either bare metal or drug-eluting stents who are not at high risk of bleeding, we suggest one year of dual antiplatelet therapy. In patients at high risk of bleeding, our recommended duration of therapy is one and six months, respectively. (See "Antiplatelet therapy after coronary artery stenting", section on 'Early noncardiac surgery or gastrointestinal endoscopy'.)

While the optimal duration of dual antiplatelet therapy for stented patients is not known, we are concerned that the proinflammatory and prothrombotic risks of surgery may increase the baseline risk of stent thrombosis even in the presence of DAT if a significant percent of struts are not endothelialized. In addition, one cannot predict the possibility that DAT might have to be stopped due to unexpected major bleeding. Thus, we recommend caution in performing elective noncardiac surgery prior to the minimal recommended duration of such therapy. Although the minimal duration of such therapy is four weeks for BMS, we recommend waiting six weeks given our concerns about the possible increased risk of stent thrombosis in the perioperative period.


If surgery must be performed before the minimum time period for dual antiplatelet therapy (generally one year in patients not at high bleeding risk), we suggest that an attempt be made to defer it for at least six weeks after placement of a bare-metal stent and at least six months after a drug-eluting stent. In these patients, a platelet P2Y12 receptor blocker should be discontinued for as brief a period as possible. Aspirin should be continued through the perioperative period, since the risk of stent thrombosis is further increased with the cessation of both aspirin and clopidogrel and surgery can usually be safely performed on aspirin.

 

[BLADEMDA]

It's my understanding the risk to the patient is greatest in the first 6 weeks regardless of stent type, with the greatest post-operative risk being in the week following surgery. If the patient felt comfortable taking a 10 - 20% risk of cardiac event or death, signed his name to a consent detailing his increasing risks which was witnessed in writing by his next of kin, the surgeon/cardiologist agreed to close inpatient cardiac monitoring for 1 week postoperatively, should we do the surgery?

Is our adherence to guidelines best for this specific patient or are we just reducing our liability by following them?

Slim,

Here is case scenario number 1:

26 year old ASA 1 rapper dude shows up for a knee arthroscopy. Healthy. ASA 1. On the way to the hospital he stopped at Burger King for a BK Broiler Sandwich and Fries. He had a Malt liquor to help get it all down. This was about 2 hours ago. Surgeon and patient want to proceed with the surgery. Patient states he understands the increased risk of aspiration but wants to go ahead anyway as a he as gig in another city in 3 days.

Do you proceed with the anesthesia after documenting the conversation about increased risk?


Case Scenario number 2:

Patient presents for ELECTIVE cath lab procedure due to Peripheral Vascular disease. He had 2 drug Eluting Stents placed 2 weeks ago. Surgeon and Patient want to proceed despite a 5-10 fold increased risk of mortality vs waiting at least 1 year. Dual Antiplatelet Drugs will be continued unless there is a complication during the surgery.

Do you proceed with the anesthesia after documenting the conversation about increased risk?

 

[BLADEMDA]

 

[Orin]

I agree, it's probably not worth it for every case and one should just defer to guidelines for the quick simple answer. Still, I like to think sometimes and not just blindly follow coz the guidelines say so. I have a few minutes so let me play your game Dr Blade.

26 year old ASA 1 rapper dude shows up for a knee arthroscopy. Healthy. ASA 1. On the way to the hospital he stopped at Burger King for a BK Broiler Sandwich and Fries. He had a Malt liquor to help get it all down. This was about 2 hours ago. Surgeon and patient want to proceed with the surgery. Patient states he understands the increased risk of aspiration but wants to go ahead anyway as a he as gig in another city in 3 days.

Can you straw man it some more? This is a completely elective surgery for an unclear indication with increased risk because of the patient's own choices and actions, which can be readily addressed and brought down to baseline by waiting 6 hours or 24h. There's minimal material gain to the patient by doing it now and only substantial risk. Though that begs the question, what's the risk of aspiration after eating two hours ago? I don't know a number. If he agreed to vomit up his partially digested food using his own fingers, had a NG put down, got IV reglan, famotidine, clinda, followed by some Bicitra, and then got RSI'd, is it cool? Would the lawyers be okay ? This is just silly.

Case Scenario number 2:

Patient presents for ELECTIVE cath lab procedure due to Peripheral Vascular disease. He had 2 drug Eluting Stents placed 2 weeks ago. Surgeon and Patient want to proceed despite a 5-10 fold increased risk of mortality vs waiting at least 1 year. Dual Antiplatelet Drugs will be continued unless there is a complication during the surgery.

That's a fun question. It's not exactly the same as the scenario the OP posted though or Excalibur's real world depiction as the detail isn't there.

Lets use the UpToDate entry you're looking at to answer it. I'll reference it since you are capable of copy/pasting the body but not the link above it or at least the name of the thing you're referencing.

http://www.uptodate.com/contents/el...gery-after-percutaneous-coronary-intervention

Lets use their "best" study, the Wijeysundera et al retrospective cohort study, though I like the Cruden et al retrospective cohort study better; you know, the one they mentioned in the article that you didn't quote or bold or highlight a little lower down coz it reiterates what I said. (http://circinterventions.ahajournals.org/content/3/3/236.long) Let me quote it for you.

In a study of 1953 patients who received either BMS or DES and subsequently underwent noncardiac surgery, there was no significant difference in the rate of in-hospital mortality or ischemic cardiac events between the two types of stents (13.3 versus 14.6 percent, respectively) [1]. These events occurred more frequently when surgery was performed within 42 days of stent implantation (42 versus 13 percent beyond 42 days) and when PCI had been performed in the setting of an acute coronary syndrome (65 versus 32 percent).

Anyway, here's the first article, which is a good one to go through. I appreciate you giving me something to review.
http://circ.ahajournals.org/content/126/11/1355.long
For the TLDR crowd, it's a cohort of >40 YO Canadians with PCIs between 2003-2009 having major noncardiac surgery. The usual $h!t applies, the DES folks are sicker, have worse lesions, etc, than the BMS folks. Just check out the tables if you care, but whatever, lets look at their results.

They show increased 30-d major cardiac mortality with folks that have BMS or DES and MAJOR noncardiac surgery. You all know the data the paper quotes that any "noncardiac surgery is associated with a proinflammatory and prothrombotic state." However, this group didn't care about low risk ambulatory surgeries coz they didn't think it would be a high risk group. So I guess those are okay to do regardless, though I would think they stir up inflammation and nastiness too. Either way, this is for big surgeries stirring up a lot of inflammation so does it apply to a minor vascular cath lab procedure? Case scenario two might be G2G. I don't know. I wish someone had looked at it in their study.

Lets see if images work here.

So at 30d out, DES has more risk than BMS. But if you read their paper and look at the supplemental data,figure 3 for 1 year mortality, there is no difference between the two.

Then if you look at that above figure closely, they show the risk for a similar cohort of 300K+ folks who didn't have a PCI but had similar major noncardiac surgery(the dashed horizontal lines). What's their risk of cardiac events?

For folks with a relative cardiac risk index (RCRI) of 3, it's no different for a BMS and surgery within 45 days or no stent and surgery with 45d. For folks with a RCRI of 4 or more, I oughta put a BMS stent in first and then do surgery within 45d coz the data suggest it is twice as safe!!! Anyone one wanna step up to the mic for that discussion?

For the DES, the first 45 days suck for major noncardiac surgery, but after that the falloff is steep. When you start looking at their outcomes vs people with similar RCRIs, there doesn't seem to be much increased risk of cardiac event at all. Does the patient in case scenario 2 have DM requiring insulin? That and his suprainguinal vascular surgery get him to a RCRI of 2, so I would probably strongly recommend waiting till he gets to 45 days out when it would be a huge drop in his risk, equivalent to his cohort of people with a similar RCRI.

What's kinda funny about this study is that they actually show increased risk for BMS and surgery between 181 and 365 days as compared to 46-180 days. I guess we should make sure those guys get in quickly during that window? Interestingly, their multivariate analysis also suggests a sweet spot of 181 - 365 days is safer for DES than the others. I don't know, that sounds funny. Statistics are evil.

So yeah, I guess this is where I'd have to sit down with the patient, the surgeon, the cardiologist, and try to figure out what the best risk/benefit is in this situation. It's tough being a doctor. It would probably take more than the usual 5-15 minutes spent in my pre-op and ruin my whole flow. But you know some places have pre-op clinics for this specific problem. It's probably not worth it for every case and one should just defer to guidelines for the quick simple answer. But in the specific case of an individual such as described in the OP and by Excalibur who is just going to languish and likely worsen clinically for the wait, I'd like to think it's worth a discussion. I know; the lawyers will have a field day coz it's too hard to explain this to a jury.

 

[BLADEMDA]

Follow the guidelines Slim unless you have a real urgent reason not to.
Clearly, you have never been to a deposition or a real trial.
If you don't have a good reason for increasing the risk of mortality to a patient and the outcome is bad then get ready to write the check. You won't stand a chance

 

[BLADEMDA]

The expert in this situation isn't an Anesthesiologist. I would defer to the cardiology society on this issue hence follow the guidelines.

I can guarantee you that if a patient dies under your care or in the perioperative setting the case will be reviewed. If a "Cowboy" Anesthesiologist decides to start picking and choosing among the data in order to avoid the accepted guidelines by the majority of practitioners then when a bad outcome occurs the Cowboy is going to get scalped.


Here is as far as I would be willing to stretch the guidelines:

we suggest that an attempt be made to defer it for at least six weeks after placement of a bare-metal stent and at least six months after a drug-eluting stent

 

[BLADEMDA]

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2.Berger PB, Kleiman NS, Pencina MJ, et al. Frequency of major noncardiac surgery and subsequent adverse events in the year after drug-eluting stent placement results from the EVENT (Evaluation of Drug-Eluting Stents and Ischemic Events) Registry. JACC Cardiovasc Interv 2010; 3:920.
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4.Hawn MT, Graham LA, Richman JR, et al. The incidence and timing of noncardiac surgery after cardiac stent implantation. J Am Coll Surg 2012; 214:658.
5.Ka&#322;uza GL, Joseph J, Lee JR, et al. Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol 2000; 35:1288.
6.Wilson SH, Fasseas P, Orford JL, et al. Clinical outcome of patients undergoing non-cardiac surgery in the two months following coronary stenting. J Am Coll Cardiol 2003; 42:234.
7.Reddy PR, Vaitkus PT. Risks of noncardiac surgery after coronary stenting. Am J Cardiol 2005; 95:755.
8.Holmes DR Jr, Kereiakes DJ, Garg S, et al. Stent thrombosis. J Am Coll Cardiol 2010; 56:1357.
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10.Rajagopalan S, Ford I, Bachoo P, et al. Platelet activation, myocardial ischemic events and postoperative non-response to aspirin in patients undergoing major vascular surgery. J Thromb Haemost 2007; 5:2028.
11.Li N, Astudillo R, Ivert T, Hjemdahl P. Biphasic pro-thrombotic and inflammatory responses after coronary artery bypass surgery. J Thromb Haemost 2003; 1:470.
12.Libby P, Theroux P. Pathophysiology of coronary artery disease. Circulation 2005; 111:3481.
13.Mahla E, Lang T, Vicenzi MN, et al. Thromboelastography for monitoring prolonged hypercoagulability after major abdominal surgery. Anesth Analg 2001; 92:572.
14.Samama CM, Thiry D, Elalamy I, et al. Perioperative activation of hemostasis in vascular surgery patients. Anesthesiology 2001; 94:74.
15.Beving H, Zhao C, Albåge A, Ivert T. Abnormally high platelet activity after discontinuation of acetylsalicylic acid treatment. Blood Coagul Fibrinolysis 1996; 7:80.
16.Ferrari E, Benhamou M, Cerboni P, Marcel B. Coronary syndromes following aspirin withdrawal: a special risk for late stent thrombosis. J Am Coll Cardiol 2005; 45:456.
17.Biondi-Zoccai GG, Lotrionte M, Agostoni P, et al. A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50,279 patients at risk for coronary artery disease. Eur Heart J 2006; 27:2667.
18.Schouten O, van Domburg RT, Bax JJ, et al. Noncardiac surgery after coronary stenting: early surgery and interruption of antiplatelet therapy are associated with an increase in major adverse cardiac events. J Am Coll Cardiol 2007; 49:122.
19.Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999; 100:1043.
20.Wijeysundera DN, Wijeysundera HC, Yun L, et al. Risk of elective major noncardiac surgery after coronary stent insertion: a population-based study. Circulation 2012; 126:1355.
21.Chassot PG, Delabays A, Spahn DR. Perioperative antiplatelet therapy: the case for continuing therapy in patients at risk of myocardial infarction. Br J Anaesth 2007; 99:316.
22.Burger W, Chemnitius JM, Kneissl GD, Rücker G. Low-dose aspirin for secondary cardiovascular prevention - cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation - review and meta-analysis. J Intern Med 2005; 257:399.
23.Singla S, Sachdeva R, Uretsky BF. The risk of adverse cardiac and bleeding events following noncardiac surgery relative to antiplatelet therapy in patients with prior percutaneous coronary intervention. J Am Coll Cardiol 2012; 60:2005.
24.Dweck MR, Cruden NL. Noncardiac surgery in patients with coronary artery stents. Arch Intern Med 2012; 172:1054.
25.Brilakis ES, Banerjee S, Berger PB. Perioperative management of patients with coronary stents. J Am Coll Cardiol 2007; 49:2145.
26.Fleisher LA, Beckman JA, Brown KA, et al. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American college of cardiology foundation/American heart association task force on practice guidelines. Circulation 2009; 120:e169.
27.Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e326S.
28.Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol 2011; 58:e44.
29.Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS), European Association for Percutaneous Cardiovascular Interventions (EAPCI), Wijns W, et al. Guidelines on myocardial revascularization. Eur Heart J 2010; 31:2501.
30.Savonitto S, D'Urbano M, Caracciolo M, et al. Urgent surgery in patients with a recently implanted coronary drug-eluting stent: a phase II study of 'bridging' antiplatelet therapy with tirofiban during temporary withdrawal of clopidogrel. Br J Anaesth 2010; 104:285.
31.Rassi AN, Blackstone E, Militello MA, et al. Safety of "bridging" with eptifibatide for patients with coronary stents before cardiac and non-cardiac surgery. Am J Cardiol 2012; 110:485.
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[BLADEMDA]

Circulation. 2012 Sep 11;126(11):1355-62. doi: 10.1161/CIRCULATIONAHA.112.102715. Epub 2012 Aug 14.

Risk of elective major noncardiac surgery after coronary stent insertion: a population-based study.

Wijeysundera DN, Wijeysundera HC, Yun L, W&#261;sowicz M, Beattie WS, Velianou JL, Ko DT.


Source

Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada. [email protected]


Abstract


BACKGROUND:

Guidelines recommend that noncardiac surgery be delayed until 30 to 45 days after bare-metal stent implantation and 1 year after drug-eluting stent implantation.

METHODS AND RESULTS:

We used linked registry data and population-based administrative health care databases to conduct a cohort study of 8116 patients (&#8805;40 years of age) who underwent major elective noncardiac surgery in Ontario, Canada between 2003 and 2009, and received coronary stents within 10 years before surgery. Approximately 34% (n=2725) underwent stent insertion within 2 years before surgery, of whom 905 (33%) received drug-eluting stents. For comparison, we assembled a separate cohort of 341 350 surgical patients who had not undergone coronary revascularization. The primary outcome was 30-day major adverse cardiac events (mortality, readmission for acute coronary syndrome, or repeat coronary revascularization). The overall rate of 30-day events in patients with coronary stents was 2.1% (n=170). When the interval between stent insertion and surgery was <45 days, event rates were high for bare-metal (6.7%) and drug-eluting (20.0%) stents. When the interval was 45 to 180 days, the event rate for bare-metal stents was 2.6%, approaching that of intermediate-risk nonrevascularized individuals. Adjusted analyses suggested that event rates were increased if this interval exceeded 180 days. For drug-eluting stents, the event rate was 1.2% once the interval exceeded 180 days, approaching that of intermediate-risk nonrevascularized individuals.

CONCLUSIONS:

The earliest optimal time for elective surgery is 46 to 180 days after bare-metal stent implantation or >180 days after drug-eluting stent implantation.

 

[VentdependenT]

Good stuff