Friend or enemy: The drug eluting stent

[VentdependenT]

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We had an M&M the presented today:

60 something dude with some obesity and hx of CAD comming in for l4 laminectomy and l5-s1 fusion.

Drug eluting stent placed 3 yrs ago! Got a cardiac cath and a friggen dobutamine stress echo. Both normal. So hes good to go. Stop asa and plavix 7 d prior.

Intraop no probs. Crappy leads smooshed on the back of the patient didn't detect any ischemia. You know how we gotta just slap those suckers on there once the flip is made. CV stable throughout. Extubated to PACU.

In PACU pt has some vauge chest/back pain, st depression in a lead. So 12 lead is done and shows ant-lat ischemia. NITRO/METOPROLOL/Stat Cards consult...off to cath lab. Saved the guys heart.

How long do you guys recommend waiting after a stent is placed?

Do you continue ASA if you can?

Anyother points on postop MI's and stents?

 

[Noyac]

I went through this not too long ago. If it is a drug eluting stent you wait 1yr. If It is not drug eluting you wait 3-6 months. You want to continue ASA if possible and start back on anti-platelet drugs as soon as possible.

 

[jetproppilot]

Drug eluting stent placed 3 yrs ago! Got a cardiac cath and a friggen dobutamine stress echo. Both normal. So hes good to go. Stop asa and plavix 7 d prior.

Intraop no probs. Crappy leads smooshed on the back of the patient didn't detect any ischemia. You know how we gotta just slap those suckers on there once the flip is made. CV stable throughout. Extubated to PACU.

In PACU pt has some vauge chest/back pain, st depression in a lead. So 12 lead is done and shows ant-lat ischemia. NITRO/METOPROLOL/Stat Cards consult...off to cath lab. Saved the guys heart.


Anyother points on postop MI's and stents?

These cases intrigue me. Thanks for the post, Venty.

Mil, Noy et al, follow me and give me your opinions.

Pretty routine case. Probably not alotta blood loss. Probably pretty stable hemodynamics intraop.

Do you think stenosis had progressed pre-op but went unidentified? Yeah, he had surgery and GA but MVO2 is probably less during GA...again assuming no persistent tachycardia, etc

We put people to sleep for CABGs every day with critical-multivessel-stenoses and the incidence of permanent myocardial sequelae from the operation/anesthesia itself is very low.

Whatcha think?

And Venty, was he beta-blocked before the surgery?

 

[Gern Blansten]

The problem is that when the stents occlude, it presents as an acute myocardial event, not a gradual ischemia that you might see with native arteries. The stent thromboses and it happens VERY quickly. Three years is a very long time for it to still be a problem, but I have heard that more cases like this are popping up. I believe the CYPHER stent recommends 3 months and the TAXUS stent recommends 6 months of Plavix uninterrupted prior to any elective surgeries. I have heard they are considering extending that out even further. It makes you wonder as you stated in your topic. If they limit your treatment options for other coexisting problems(ie appy, chole, colectomy for cancer, orthopedic procedures, etc) in the future, have you really gained anything by having the DES as opposed to the bare metal stent. This issue is a real dilemma that we don't know all of the answers to yet.

 

[deleted87051]

The problem is that when the stents occlude, it presents as an acute myocardial event, not a gradual ischemia that you might see with native arteries. The stent thromboses and it happens VERY quickly.

I was wondering about this too. Did the patient have acute stent occlusion or progressive disease in a native vessel? Presentation does not seem like typical catastrophic stent occlusion. Maybe it was the early diagnosis and intervention.

 

[dhb]

I was wondering about this too. Did the patient have acute stent occlusion or progressive disease in a native vessel? Presentation does not seem like typical catastrophic stent occlusion. Maybe it was the early diagnosis and intervention.

Yeah, a progressive disease will more likely manifest itself like effort related angina (not likely here if no blood loss, tachy..) while you need a vessel thrombosis to get your acute MI.
In this case the presentation might be sub-acute because the myocardium perfused down-stream of the stent had already suffered some necrosis in the past...

 

[militarymd]

The guy got cathed....what's the result?

 

[VentdependenT]

These cases intrigue me. Thanks for the post, Venty.

Mil, Noy et al, follow me and give me your opinions.

Pretty routine case. Probably not alotta blood loss. Probably pretty stable hemodynamics intraop.

Do you think stenosis had progressed pre-op but went unidentified? Yeah, he had surgery and GA but MVO2 is probably less during GA...again assuming no persistent tachycardia, etc

We put people to sleep for CABGs every day with critical-multivessel-stenoses and the incidence of permanent myocardial sequelae from the operation/anesthesia itself is very low.

Whatcha think?

And Venty, was he beta-blocked before the surgery?

Dude was beta blocked preop by his outside cards dude. HR in 60's 70's throughout case.

Replying to Noyac's post about his length of time rec's:

Seems some common recs are

xigris stent: wait 3 months for re-endothelialization. continue antiplatelet drugs fer a year at least

Paclitaxil stent: wait 6 months for re-endothelialization. cont antiplatelet for at least a year.

Anypoops,

What is interesting though it seems these folks may remain INDEFINITELY thrombogenic in their stent region regardless of time after placement. X years out and dudes are havin MI's because of documented clots in the stented region (not the sole source of ischemia in all events I'm pretty sure).

We know its a gamble once they are off the antiplatelet meds, but how big of a gamble is it after a year? I dunno man. I ain't pullen no lit search out. However I don't think there is a lot of data out there besides gathered case reports.

 

[VentdependenT]

The guy got cathed....what's the result?

I'll ask the attending where they found the infarct at. If indeed it was in the stented region I dunno. I do recall that it was a 100% occlusion. Kinda funky considering a not too distant cath was clean preop.

 

[Noyac]

I have the article which states the new recs if I can find it.