DES and elective THA.

[sevoflurane]

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So last week I was presented with a patient who was 5 months out from placement of a PDA DES for elective THA.

I get to pre-op, read the chart and the cardiologist has "cleared" the patient so long as we continue ASA and Plavix.

How do you proceed? Any concerns?

 

[BLADEMDA]

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.


http://circ.ahajournals.org/content/126/11/1355.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.

 

[BLADEMDA]

So last week I was presented with a patient who was 5 months out from placement of a PDA DES for elective THA.

I get to pre-op, read the chart and the cardiologist has "cleared" the patient so long as we continue ASA and Plavix.

How do you proceed? Any concerns?

1. I'd delay the case for another month. I know my partners would do the case because "Cards cleared him" but I wouldn't do it.
2. He is going to bleed a lot more on the Plavix so better have a cell saver in the room
3. Type and Cross 2 units of Prbcs
4. Arterial line and large bore IV access
5. No blocks except a FICB so GA with ETT
6. TXA is controversial here

Explain to the patient the blood thinners increase the risk of him needing a transfusion and ICU stay.

 

[BLADEMDA]

Timing, incidence, and clinical predictors — Multiple observational studies have evaluated the timing, incidence, and clinical predictors of adverse outcomes in stented patients undergoing noncardiac surgery. They have shown that patients who undergo major noncardiac surgery within six weeks, and particularly within two weeks, of PCI with bare-metal (BMS) or drug-eluting stents (DES) have an increased risk of adverse cardiovascular events [1,4,6-8,17-19]. This increased risk extends for as long as six months after DES placement

 

[IMED4Life]

We see this all the time. Initially I balked as ACC recs were 1 year on anti platelet Rx. However our Cardiologists have stated minimum of 6 months on Rx followed by LMWH bridge (7 day) Rx prior to surgery. This also allows for SAB. As a compromise our orthopods have agreed to our objection to tranexamic acid use in these patients. So far, no periop thrombotic episodes noted.
Regarding your case, I'd highlight the list of guidelines from ACC/AHA as well as the guidelines from British Journal of Anaesthesia should your Cardiologist refute your claims.
The common issue I run into is the Cardiologists are reluctant to delay an elective case even if it comes at the expense of the heart! An example I come across is when a patient has an EF <30% and would benefit from an AICD, but the Cardiologist would rather wait until AFTER the shoulder arthoplasty. And the orthopod's reply:"well, they were CLEARED by Cardiology."

 

[BLADEMDA]

SUMMARY AND RECOMMENDATIONS
●Noncardiac surgery is often required in patients taking dual antiplatelet therapy (DAT) after percutaneous coronary intervention (PCI) with stenting. Cessation of DAT prior to the recommended duration of its use as well as the prothrombotic and proinflammatory state associated with surgery contribute to an increased risk of adverse cardiovascular events such as stent thrombosis, myocardial infarction, or death. On the other hand, for some patients such as those undergoing neurosurgical procedures, the risk of bleeding attributable to DAT may be greater than the risk of an adverse cardiovascular event off such therapy. (See 'Introduction' above and 'Death, MI, stent thrombosis, and revascularization' above.)
●The following are our recommendations for patients taking DAT after PCI with stenting for whom elective noncardiac surgery is needed. The rationale for the durations presented below is given above (see 'Elective noncardiac surgery in stented patients' above):
•We suggest deferring surgery for at least six months and preferably one year, as opposed to operating sooner, irrespective of stent type (Grade 2C).
•In patients who cannot wait at least one year for noncardiac surgery, we recommend that an attempt be made to defer surgery for at least six weeks after stent placement (Grade 1B).
•For most patients undergoing noncardiac surgery who are taking DAT after PCI with stenting because they have not reached the recommended duration of such therapy, we suggest continuing DAT, as opposed to stopping it prior to surgery (Grade 2C).

In patients for whom the risk of bleeding is likely to exceed the risk of a perioperative event due to the premature cessation of DAT, it is reasonable to continue aspirin alone. In patients for whom a bleeding complication could be catastrophic, such as patients undergoing neurosurgical, prostate, or posterior eye procedures, stopping both antiplatelet agents might be reasonable.
●For patients taking DAT after PCI with balloon angioplasty who are scheduled to undergo elective noncardiac surgery, we suggest waiting at least 14 days after PCI (Grade 2C). (See 'Patients with prior balloon angioplasty' above.)
●Recommendations for patients taking long-term aspirin monotherapy undergoing noncardiac surgery and for patients undergoing coronary artery bypass graft surgery on DAT are found elsewhere. (See "Perioperative medication management", section on 'Aspirin' and "Medical therapy to prevent complications after coronary artery bypass graft surgery", section on 'Preoperative aspirin' and "Medical therapy to prevent complications after coronary artery bypass graft surgery", section on 'Platelet P2Y12 receptor blocker therapy'.)

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

 

[BLADEMDA]

ST= Stent Thrombosis



The risk of ST is particularly increased in the highly thrombogenic environment of a perioperative period, which is associated with augmented release of endogenous catecholamines, platelet activation and hypercoagulability.12,13 Adverse cardiac events typically develop in the early post-operative period (within the first 24 hours) requiring clinical awareness and thorough monitoring of the electrocardiographic pattern, as well as clinical and hemodynamic status. It is strongly recommended that non-cardiac surgery in patients after PCI will be carried out in institutions with immediate PCI availability, to provide timely definitive treatment of ST.

http://www.invasivecardiology.com/a...non-cardiac-surgery-learning-lessons-hard-way

 

[Planktonmd]

You or the surgeon asked a consultant to give an opinion and he did...
He said go ahead but don't stop aspirin and plavix...
This is a little problematic, because although the input from the consultant is in favor of proceeding and ignoring the magical 6 months wait, proceeding with elective hip surgery under plavix and aspirin carries the risk of intra and postop bleeding that outweighs the benefit of this surgery.
I would call the cardiologist and tell him we will do this purely elective surgery when he can tell us that it's OK to stop the anti platelet therapy.

 

[sevoflurane]

ST= Stent Thrombosis



The risk of ST is particularly increased in the highly thrombogenic environment of a perioperative period, which is associated with augmented release of endogenous catecholamines, platelet activation and hypercoagulability.12,13 Adverse cardiac events typically develop in the early post-operative period (within the first 24 hours) requiring clinical awareness and thorough monitoring of the electrocardiographic pattern, as well as clinical and hemodynamic status. It is strongly recommended that non-cardiac surgery in patients after PCI will be carried out in institutions with immediate PCI availability, to provide timely definitive treatment of ST.

No one likes to give a transfusion, but a transfusion won't kill 'em.

My biggest beef is quoted above. Restenosis/occlusion of a stent (particularly left main, LAD, etc) in the thrombogenic environment. Does dual platelet therapy negate the effects of thrombogenic factors? Every single orthopedic implant that gets POUNDED in will invariably release micro-fat embolisms. What does a fat globule do when it encounters a foreign stent that hasn't been entirely endothelialized? I don't know.

I am seeing more and more patients being cleared for elective surgeries (with dual platelet therapy) before the full 12 months of anticoagulation has been completed.
I'm wondering if there is debate on this topic and if guidelines may be changing.

Stent thrombosis is an uncommon but serious complication that almost always presents as death or a large non-fatal myocardial infarction (MI), usually with ST elevation. It is estimated that less than 10 percent of cardiac deaths after stent placement are attributable to stent thrombosis, with most of the remainder being due to disease progression [1].
http://www.uptodate.com/contents/coronary-artery-stent-thrombosis-incidence-and-risk-factors

I don't know about you guys, but 10% does not sound like something that is acceptable.

 

[pgg]

I'd have cancelled it. Elective surgery 5 months out from a DES? No.


I can't remember the last time I saw a cardiologist NOT clear a patient for surgery. I don't have much use for them, beyond:
1) I'd like to see the data from any studies they might have done.
2) For semi-urgent cases like hip fractures I like to see some statement that the patient is not in failure and won't benefit from 24-48 hrs of optimization.
3) I won't ever tell patients to halt their antiplatelet therapy, even after the initial elective surgery no-bueno period for stents, so I rely on the cardiologist to make that recommendation in writing. Or the surgeon can do it, if he's that bold.

What else are they good for? I'll do the "clear for surgery" myself thankyouverymuch.

 

[periopdoc]

European data suggest 6 months as good as 1 year so yes there is debate in cardiology community.

I've done THAs on dual therapy and they suck.

I would do it when cardiologist is comfortable with pt being off tx.

-pod

 

[BLADEMDA]

European data suggest 6 months as good as 1 year so yes there is debate in cardiology community.

I've done THAs on dual therapy and they suck.

I would do it when cardiologist is comfortable with pt being off tx.

-pod

Or willing to bridge therapy with Lovenox/LMWH for 7 days so the Plavix can be stopped in order to decrease intraop bleeding and allow a Neuraxial technique. That said, the patient must be 180 days or more out from his DES placement in order for me to proceed.

 

[Noyac]

Or willing to bridge therapy with Lovenox/LMWH for 7 days so the Plavix can be stopped in order to decrease intraop bleeding and allow a Neuraxial technique. That said, the patient must be 180 days or more out from his DES placement in order for me to proceed.

Your not saying Lovenox is as effective as plavix, are you?

 

[napman]

Risk of major adverse cardiac events following noncardiac surgery in patients with coronary stents.

JAMA. 2013 Oct 9;310(14):1462-72. doi: 10.1001/jama.2013.278787

IMPORTANCE:
Guidelines recommend delaying noncardiac surgery in patients after coronary stent procedures for 1 year after drug-eluting stents (DES) and for 6 weeks after bare metal stents (BMS). The evidence underlying these recommendations is limited and conflicting.
OBJECTIVE:
To determine risk factors for adverse cardiac events in patients undergoing noncardiac surgery following coronary stent implantation.
DESIGN, SETTING, AND PARTICIPANTS:
A national, retrospective cohort study of 41,989 Veterans Affairs (VA) and non-VA operations occurring in the 24 months after a coronary stent implantation between 2000 and 2010. Nonlinear generalized additive models examined the association between timing of surgery and stent type with major adverse cardiac events (MACE) adjusting for patient, surgery, and cardiac risk factors. A nested case-control study assessed the association between perioperative antiplatelet cessation and MACE.
MAIN OUTCOMES AND MEASURES:
A composite 30-day MACE rate of all-cause mortality, myocardial infarction, and cardiac revascularization.
RESULTS:
Within 24 months of 124,844 coronary stent implantations (47.6% DES, 52.4% BMS), 28,029 patients (22.5%; 95% CI, 22.2%-22.7%) underwent noncardiac operations resulting in 1980 MACE (4.7%; 95% CI, 4.5%-4.9%). Time between stent and surgery was associated with MACE (<6 weeks, 11.6%; 6 weeks to <6 months, 6.4%; 6-12 months, 4.2%; >12-24 months, 3.5%; P < .001). MACE rate by stent type was 5.1% for BMS and 4.3% for DES (P < .001). After adjustment, the 3 factors most strongly associated with MACE were nonelective surgical admission (adjusted odds ratio [AOR], 4.77; 95% CI, 4.07-5.59), history of myocardial infarction in the 6 months preceding surgery (AOR, 2.63; 95% CI, 2.32-2.98), and revised cardiac risk index greater than 2 (AOR, 2.13; 95% CI, 1.85-2.44). Of the 12 variables in the model, timing of surgery ranked fifth in explanatory importance measured by partial effects analysis. Stent type ranked last, and DES was not significantly associated with MACE (AOR, 0.91; 95% CI, 0.83-1.01). After both BMS and DES placement, the risk of MACE was stable at 6 months. A case-control analysis of 284 matched pairs found no association between antiplatelet cessation and MACE (OR, 0.86; 95% CI, 0.57-1.29).
CONCLUSIONS AND RELEVANCE:
Among patients undergoing noncardiac surgery within 2 years of coronary stent placement, MACE were associated with emergency surgery and advanced cardiac disease but not stent type or timing of surgery beyond 6 months after stent implantation. Guideline emphasis on stent type and surgical timing for both DES and BMS should be reevaluated.

 

[sevoflurane]

Maybe the guidlines will be changing. 1 year is def. over conservative. A minimum of 6 months sounds about right based on new data. Left main, LAD, Circ, RCA etc., should prolly get more than 6 months until the water clears out a little.
When I start getting patients 5 months out, evasive maneuvers are the way to go... although I hate cancelling cases.

As for doing an elective THA case on plavix and ASA...? That's nonsense.
These individuals will end up with a blood transfusion... and although it won't kill 'em, why get someone else's blood products unecessarily. Eeew.

 

[dhb]

Have you seen patients with these new biodegradable stents? anti-platelets can be stopped after 3 months in case of surgery