Management of Patients with Drug-Eluting Stents Undergoing Surgery

Introduction to Stent Management

The American College of Cardiology and American Heart Association guidelines recommend that elective procedures with significant bleeding risk should be deferred until patients complete 12 months of thienopyridine therapy after drug-eluting stent implantation, due to the high risk of stent thrombosis associated with premature discontinuation of dual antiplatelet therapy 1, 2, 4
The French Task Force consensus recommends maintaining combination antiplatelet treatment for at least 6-12 months after DES placement, to minimize the risk of stent thrombosis 3, 5
The American College of Chest Physicians recommends deferring surgery for at least 6 months after drug-eluting stent placement, to reduce the risk of adverse cardiac events 6

The highest risk of stent thrombosis occurs within the first 6 weeks after stent placement, with an adverse event rate of 8-10% 7
The risk plateaus at 6 months, with an adverse event rate of 1-2%, and remains stable at 24 months 7
More recent evidence suggests that the increased risk is statistically significant primarily when surgery occurs within 1 month of stenting, highlighting the importance of careful timing and risk assessment 8, 7

The 2022 ACCP guidelines suggest that if surgery is truly urgent and cannot be delayed to 6-12 months, either continuing both antiplatelet agents perioperatively or stopping one antiplatelet agent 7-10 days before surgery may be considered, with aspirin continued if at all possible and the P2Y12 inhibitor restarted as soon as possible after the procedure 8, 7
Aspirin should be continued if at all possible, and the P2Y12 inhibitor should be restarted as soon as possible after the procedure, to minimize the risk of stent thrombosis 1, 2, 4

Never discontinue both aspirin and clopidogrel simultaneously in patients with recent stent placement, as this significantly increases the risk of stent thrombosis, with a hazard ratio of 13.74 9, 10
If clopidogrel must be stopped, it should be withdrawn for only a 5-day window, with aspirin maintained throughout, to minimize the risk of adverse cardiac events 3, 5, 11
Never substitute antiplatelet agents with heparin or low-molecular-weight heparin, as these do not adequately protect against stent thrombosis 9, 10

Certain patients have even higher risk of stent thrombosis and require extra caution, including those with a history of previous stent thrombosis, multiple stents, long stents, or stents at bifurcations, incomplete revascularization, and low ejection fraction 3, 5, 10

Do not place drug-eluting stents in patients with planned surgery within 6-12 months, as this increases the risk of stent thrombosis and adverse cardiac events; instead, use bare-metal stents, which only require 4-6 weeks of DAPT 1, 2, 3
Do not assume the risk disappears at exactly 12 months, as clinicians should remain vigilant even beyond 365 days after DES placement, and consider the individual patient's risk factors and clinical circumstances 4