Management of Dual Antiplatelet Therapy for Peripheral Stents

Duration of DAPT Based on Stent Type

For patients with peripheral stents, the American College of Cardiology recommends dual antiplatelet therapy (DAPT) should be maintained for at least 4-6 weeks after placement of a bare metal stent and at least 6-12 months after placement of a drug-eluting stent to reduce the risk of stent thrombosis 1, 2
Bare metal stents require DAPT for at least 4-6 weeks, according to the British Journal of Anaesthesia guidelines 1, 2
Drug-eluting stents require DAPT for at least 6-12 months, as recommended by the British Journal of Anaesthesia 1, 2

Patients at high risk for stent thrombosis include those with discontinuation of antiplatelet therapy within 6-12 months after stent placement, as stated by the British Journal of Anaesthesia 2
A history of previous stent thrombosis is a risk factor for future stent thrombosis, according to the British Journal of Anaesthesia 2
Multiple stents or long stents increase the risk of stent thrombosis, as reported by the British Journal of Anaesthesia 2
Stents placed at bifurcations are at higher risk for thrombosis, according to the British Journal of Anaesthesia 2
Incomplete revascularization increases the risk of stent thrombosis, as stated by the British Journal of Anaesthesia 2
Diabetes mellitus is a risk factor for stent thrombosis, according to the British Journal of Anaesthesia 2
Low ejection fraction increases the risk of stent thrombosis, as reported by the British Journal of Anaesthesia 2

For minor procedures, the American College of Chest Physicians recommends continuing aspirin throughout the procedure and considering interruption of P2Y12 inhibitor (clopidogrel) if necessary 4
For major procedures with high bleeding risk, the British Journal of Anaesthesia suggests postponing elective surgery until completion of the recommended DAPT duration (6-12 months for drug-eluting stents) 5, 6
If surgery cannot be postponed, maintaining aspirin therapy throughout the perioperative period is recommended by the British Journal of Anaesthesia 1, 7
Clopidogrel may be withdrawn for a 5-day window before surgery, as stated by the British Journal of Anaesthesia 7
Resuming clopidogrel as soon as possible after surgery, preferably within 5 days, is recommended by the British Journal of Anaesthesia and Gut 6, 8

For patients with drug-eluting stents who are within 3-12 months post-implantation and require elective surgery, stopping the P2Y12 inhibitor prior to surgery is suggested while continuing aspirin, according to the American College of Chest Physicians 4
Routine bridging therapy with glycoprotein IIb/IIIa inhibitors, cangrelor, or LMWH is not recommended for most patients, as stated by the American College of Chest Physicians 4
For high-risk patients, a multidisciplinary approach involving cardiologists, surgeons, and anesthesiologists should be employed to balance thrombotic and bleeding risks, as recommended by the British Journal of Anaesthesia and the American College of Chest Physicians 4, 9

If discontinuation of one antiplatelet agent is necessary after the mandatory period, maintaining at least aspirin therapy is recommended by the British Journal of Anaesthesia 10

For patients requiring future surgery, consider using bare metal stents rather than drug-eluting stents when initially placing the stent, if appropriate, as suggested by the British Journal of Anaesthesia 5