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Recommendations regarding stent selection in relation to the timing of noncardiac surgery postpercutaneous coronary intervention

There are no control trials comparing perioperative cardiac outcome after noncardiac surgery for patients treated with preoperative percutaneous coronary intervention (PCI) versus medical therapy. Several studies, however, have demonstrated a number of complications from angioplasty, including death [1–3]. As a result, in 2002, guidelines from the American College of Cardiology (ACC)/American Heart Association (AHA) Task Force regarding PCI and noncardiac surgery were updated [4]. The executive summary concluded that “there is uncertainty regarding how much time should pass between PCI and noncardiac procedures. If a coronary stent is used, a delay of at least 2 weeks, and ideally 4 to 6 weeks, should occur before noncardiac surgery to allow 4 full weeks of dual antiplatelet therapy and re-endothelialization of the stent to be completed, or nearly so.” In this issue, my colleagues from the Washington Hospital Center identified 47 patients who underwent noncardiac surgery within 90 days of coronary stent placement. The study confirms previous findings demonstrating the high mortality in patients undergoing noncardiac surgery within 3 weeks of the PCI involving the stent (Fig. 1). The unique observation is that during the first 3 weeks after PCI, the interruption of thienopyridines resulted in a group with the highest mortality (Fig. 2). Although the numbers are small, the importance of continuing dual antiplatelet therapy after PCI with stenting is striking. In a drug-eluting stent environment, should further modifications be made to the clinical guidelines? Delayed endothelialization has been suggested with both paclitaxeland sirolimus-eluting stents [5,6]. In an autopsy performed at 16 months after a sirolimus stent was implanted into a human coronary artery in which the patient had an infarct in a second vessel, a detailed evaluation demonstrated near but not complete endothelialization [6]. Based on these findings, a reasonable approach for the management of patients undergoing noncardiac surgery is reviewed in Figure 3. The first and most important question to ask is whether revascularization is required, and if medical management remains a reasonable option, aggressive optimization of the medical program should be continued preoperatively, perioperatively, and postoperatively. For those patients who are felt to be at high risk for a major cardiac event due to an ischemic burden created by surgery, it would be reasonable to select a specific type of stent based on the subsequent timing of the noncardiac operation. For emergent surgery (i.e., surgery required within 4 weeks), the use of a bare metal stent possibly with Hepacoat or a phosphoryline coating seems reasonable as the antithrombotic coating may further limit the potential for acute thrombosis.