Outcomes of a preoperative “bridging” strategy with glycoprotein IIb/IIIa inhibitors to prevent perioperative stent thrombosis in patients with drug-eluting stents who undergo surgery, necessitating interruption of thienopyridine administration

Selected in EuroIntervention Journal by S. Brugaletta

References

Authors

Alshawabkeh LI, Prasad A, Lenkovsky F, Makary LF, Kandil ES, Weideman RA, Kelly KC, Rangan BV, Banerjee S, Brilakis ES.

Reference

EuroIntervention. 2013 Jun 22;9(2):204-11

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Aims

Surgery after drug-eluting stent (DES) implantation may be associated with increased risk for perioperative stent thrombosis (ST). Methods and results: We evaluated the outcomes of 67 patients who underwent non-cardiac (n=51) or cardiac (n=16) surgery after DES implantation at our institution between 2008 and 2010 and who underwent preoperative "bridging" with a glycoprotein IIb/IIIa inhibitor. Surgery occurred after a mean time of 13.9±1.7 and 8.7±2 months post stenting for non-cardiac (NCS) and cardiac surgery, respectively. Glycoprotein IIb/IIIa inhibitors were administered preoperatively for a mean of 7.1±0.4 and 7.8±0.7 days, respectively, then discontinued four to six hours before surgery. Most patients received aspirin through the perioperative period (33 NCS patients and 15 cardiac surgery patients). Clopidogrel was restarted as early as possible in the postoperative period. In the non-cardiac surgery group, two patients (3.9%, 95% confidence intervals 0.5% to 13.5%) suffered acute ST in the immediate postoperative period and four patients suffered major bleeding by the Global Utilisation of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) criteria. One cardiac surgery patient had probable ST one hour postoperatively. Conclusions: In spite of preoperative "bridging" with a glycoprotein IIb/IIIa inhibitor, postoperative stent thrombosis can still occur in patients with prior DES undergoing surgery requiring antiplatelet medication interruption.

My Comment

What is known

Patients with drug-eluting stents (DES) who subsequently require surgery may be at increased risk for perioperative stent thrombosis. A recent systematic literature review reported that perioperative stent thrombosis rate decreases over time from 2.3% if non-cardiac surgery is performed within six months, up to 0.9% if performed more than 12 months after DES implantation. Administration of a short-acting anticoagulant or antiplatelet regimen has been proposed to minimise the risk for perioperative stent thrombosis in such patients, when surgery cannot be postponed.

Major findings 

  •  Sixty-seven patients who underwent non-cardiac (n=51) or cardiac (n=16) surgery after DES implantation were enrolled.
  • Surgery occurred after a mean of 13.9±1.7 and 8.7±2 months post stenting for non-cardiac (NCS) and cardiac surgery, respectively.
  • Glycoprotein IIb/IIIa inhibitors were administered preoperatively for a mean of 7.1±0.4 and 7.8±0.7 days, respectively, then discontinued four to six hours before surgery.
  • Most patients received aspirin through the perioperative period (33 non-cardiac patients and 15 cardiac surgery patients). Clopidogrel was restarted as early as possible in the post- operative period.
  • In the non-cardiac surgery group, two patients (3.9%, 95% confidence intervals 0.5% to 13.5%) suffered acute ST in the immediate postoperative period and four patients suffered major bleeding by GUSTO criteria. One cardiac surgery patient had probable ST one hour postoperatively.

My comments

The present retrospective study currently represents one of the largest cohort of patients who have received a IIb/IIIa inhibitor infusion as bridging to a cardiac or no-cardiac surgery after DES implantation. Many points need to be highlighted. First of all, it is important to see that DES thrombosis occurred in some of these patients despite a large time after DES implantation (19 and 13 months). Second, the two definite stent thromboses occurred in patients who have received a DES for restenosis of another metallic stent. These patients could be considered upfront as at high-risk of developing stent thrombosis in such clinical scenario, given the high amount of metal. With this regard, it is questionable the choice to treat such stent thrombosis, caused by poor antiplatelet therapy and not by restenosis, with the implantation of another metallic stent. Third, it is also important to consider that definite stent thrombosis occurred in cases where aspirin was withdrawn. Despite surgery, aspirin should be always recommended. Eventually it is of note the high rate of bleeding events in this population, although the lack of a control group does not allow any comparison.

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