From a technical standpoint, if PCI is believed to be necessary as a prelude to noncardiac surgery, the primary factors that dictate the procedural approach are (1) the amount of time available between PCI and surgery and (2) whether the planned surgical procedure allows for continuation of antiplatelet therapy during the perioperative period (Fig. 7-7). If surgery is urgent, for a life-threatening problem, PCI is typically not performed. Stand-alone balloon angioplasty may be considered in instances in which surgery can be delayed for at least 1 week, because this approach circumvents the need for thienopyridine therapy and the possibility of perioperative stent thrombosis. As noted, however, the possibility that bailout stent placement may become necessary during attempts at balloon angioplasty should be considered. A strategy of simple balloon angioplasty may also be less likely to yield adequate results with certain disease patterns, such as multivessel or left main disease. Bare metal stent placement appears to represent the preferred approach if surgery can be postponed for preferably 6 weeks after stent placement, to permit stent endothelialization and completion and washout of thienopyridine therapy. If the bleeding risks of the
Preoperative Risk Assessment necessary
Surgery can be delayed for >6 weeks
Bare-metal stent placement - Continue aspirin through surgery, or restart as soon as possible
Figure 7-7. Technical considerations of preoperative percutaneous coronary intervention (PCI).
Surgery necessary within 2 weeks
- 10% possibility if crossover to stenting
- Restenosis is a concern if surgery is delayed for >8-12 weeks planned surgical procedure are low, such that aspirin and thienopyridine can be continued perioperatively, it may be possible, if necessary, to perform surgery 2 to 4 weeks after stent placement, although the safety of this approach remains uncertain, and postponing surgery for a full 6 weeks is recommended. At present, based almost exclusively on theoretical concerns, the use of drug-eluting stents should be avoided before planned noncardiac surgery. If a patient who has undergone recent drug-eluting stent implantation requires unexpected noncardiac surgery, the surgery should probably be delayed as long as safely possible, and aspirin and thienopyridine therapy should be reinitiated as soon as possible after surgery.
1. Ellis SG, Hertzer NR, Young JR, Brener S: Angiographic correlates of cardiac death and myocardial infarction complicating major nonthoracic vascular surgery. Am J Cardiol 1996; 77:1126-1128.
2. Mackey WC, Fleisher LA, Haider S, et al: Perioperative myo-cardial ischemic injury in high-risk vascular surgery patients: Incidence and clinical significance in a prospective clinical trial. J Vasc Surg 2006;43:533-538.
3. Landesberg G, Mosseri M, Zahger D, et al: Myocardial infarction after vascular surgery: The role of prolonged stress-induced, ST depression-type ischemia. J Am Coll Cardiol 2001;37:1839-1845.
4. Kim LJ, Martinez EA, Faraday N, et al: Cardiac troponin I predicts short-term mortality in vascular surgery patients. Circulation 2002;106:2366-2371.
5. Landesberg G, Shatz V, Akopnik I, et al: Association of cardiac troponin, CK-MB, and postoperative myocardial ischemia with long-term survival after major vascular surgery. J Am Coll Cardiol 2003;42:1547-1554.
6. Bursi F, Babuin L, Barbieri A, et al: Vascular surgery patients: Perioperative and long-term risk according to the ACC/AHA guidelines: The additive role of post-operative troponin elevation. Eur Heart J 2005;26:2448-2456.
7. Eagle KA, Berger PB, Calkins H, et al: ACC/AHA guideline update for perioperative cardiovascular evaluation for noncar-diac surgery: Executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2002;105:1257-1267.
8. Mukherjee D, Eagle KA: Perioperative cardiac assessment for noncardiac surgery: Eight steps to the best possible outcome. Circulation 2003;107:2771-2774.
9. Froehlich JB, Karavite D, Russman PL, et al: American College of Cardiology/American Heart Association preoperative assessment guidelines reduce resource utilization before aortic surgery. J Vasc Surg 2002;36:758-763.
10. Boersma E, Poldermans D, Bax JJ, et al: Predictors of cardiac events after major vascular surgery: Role of clinical characteristics, dobutamine echocardiography, and beta-blocker therapy. JAMA 2001;285:1865-1873.
11. Pierpont GL, Moritz TE, Goldman S, et al: Disparate opinions regarding indications for coronary artery revascularization before elective vascular surgery. Am J Cardiol 2004;94: 1124-1128.
12. London MJ, Zaugg M, Schaub MC, Spahn DR: Perioperative beta-adrenergic receptor blockade: Physiologic foundations and clinical controversies. Anesthesiology 2004;100:170-175.
13. Narins CR, Zareba W, Moss AJ, et al: Relationship between intermittent claudication, inflammation, thrombosis, and recurrent cardiac events among survivors of myocardial infarction. Arch Intern Med 2004;164:440-446.
14. Fleisher LA, Beckman J, Brown K, et al: ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery: Focused update on perioperative beta-
blocker therapy. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2006;47:2343-2355.
15. Poldermans D, Boersma E, Bax JJ, et al: The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echo-cardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. N Engl J Med 1999;341: 1789-1794.
16. Mangano DT, Layug EL, Wallace A, Tateo I: Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group. N Engl J Med 1996;335:1713-1720.
17. Juul AB, Wetterslev J, Kofoed-Enevoldsen A, et al: The Diabetic Postoperative Mortality and Morbidity (DIPOM) trial: Rationale and design of a multicenter, randomized, placebo-controlled, clinical trial of metoprolol for patients with diabetes mellitus who are undergoing major noncardiac surgery. Am Heart J 2004;147:677-683.
18. Yang H, Raymer K, Butler R, et al: Metoprolol After Vascular Surgery (MaVS). [Abstract.] Can J Anaesth 2004;51:A7.
19. Lindenauer PK, Pekow P, Wang K, et al: Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med 2005;353:349-361.
20. Kertai MD, Bax JJ, Klein J, Poldermans D: Is there any reason to withhold beta blockers from high-risk patients with coronary artery disease during surgery? Anesthesiology 2004;100: 4-7.
21. Lindenauer PK, Fitzgerald J, Hoople N, Benjamin EM: The potential preventability of postoperative myocardial infarction: Underuse of perioperative beta-adrenergic blockade. Arch Int Med 2004;164:762-766.
22. Devereaux PJ, Yusuf S, Yang H, et al: Are the recommendations to use perioperative beta-blocker therapy in patients undergoing noncardiac surgery based on reliable evidence? CMAJ 2004;171:245-247.
23. Lindenauer PK, Pekow P, Wang K, et al: Lipid-lowering therapy and in-hospital mortality following major noncardiac surgery. JAMA 2004;291:2092-2099.
24. Poldermans D, Bax JJ, Kertai MD, et al: Statins are associated with a reduced incidence of perioperative mortality in patients undergoing major noncardiac vascular surgery. Circulation 2003;107:1848-1851.
25. Kertai MD, Boersma E, Westerhout CM, et al: Association between long-term statin use and mortality after successful abdominal aortic aneurysm surgery. Am J Med 2004; 116: 96-103.
26. Kertai MD, Boersma E, Westerhout CM, et al: A combination of statins and beta-blockers is independently associated with a reduction in the incidence of perioperative mortality and nonfatal myocardial infarction in patients undergoing abdominal aortic aneurysm surgery. Eur J Vasc Endovasc Surg 2004;28: 343-352.
27. Schouten O, Poldermans D, Visser L, et al: Fluvastatin and bisoprolol for the reduction of perioperative cardiac mortality and morbidity in high-risk patients undergoing non-cardiac surgery: Rationale and design of the DECREASE-IV study. Am Heart J 2004;148:1047-1052.
28. Wallace AW, Galindez D, Salahieh A, et al: Effect of clonidine on cardiovascular morbidity and mortality after noncardiac surgery. Anesthesiology 2004;101:284-293.
29. Wijeysundera DN, Naik JS, Beattie WS: Alpha-2 adrenergic agonists to prevent perioperative cardiovascular complications: A meta-analysis. Am J Med 2003;114:742-752.
30. Henke PK, Blackburn S, Proctor MC, et al: Patients undergoing infrainguinal bypass to treat atherosclerotic vascular disease are underprescribed cardioprotective medications: Effect on graft patency, limb salvage, and mortality. J Vasc Surg 2004;39: 357-365.
31. Sandham JD, Hull RD, Brant RF, et al: A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 2003;348:5-14.
32. Breen P, Lee JW, Pomposelli F, Park KW: Timing of high-risk vascular surgery following coronary artery bypass surgery: A 10-year experience from an academic medical centre. Anaesthesia 2004;59:422-427.
33. Mukherjee D, Eagle KA, Smith DE, et al: Impact of extracardiac vascular disease on acute prognosis in patients who undergo percutaneous coronary interventions. Am J Cardiol 2003; 92:972-974.
34. Singh M, Lennon RJ, Darbar D, et al: Effect of peripheral arterial disease in patients undergoing percutaneous coronary intervention with intracoronary stents. Mayo Clin Proc 2004;79:1113-1118.
35. Priebe HJ: Perioperative myocardial infarction: Aetiology and prevention. Br J Anaesth 2005;95:3-19.
36. Kaluza GL, Joseph J, Lee JR, et al: Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol 2000;35:1288-1294.
37. Wilson SH, Fasseas P, Orford JL, et al: Clinical outcome of patients undergoing non-cardiac surgery in the two months following coronary stenting. J Am Coll Cardiol 2003;42: 234-240.
38. Godet G, Riou B, Bertrand M, et al: Does preoperative coronary angioplasty improve perioperative cardiac outcome? Anesthesiology 2005;102:739-746.
39. Reddy PR, Vaitkus PT: Risks of noncardiac surgery after coronary stenting. Am J Cardiol 2005;95:755-757.
40. Vicenzi M, Meislitzer T, Heitzlinger B, et al: Coronary artery stenting and non-cardiac surgery: A prospective outcome study. Br J Anaesth 2006;6:686-693.
41. Landesberg G, Mosseri M, Shatz V, et al: Cardiac troponin after major vascular surgery: The role of perioperative ischemia, preoperative thallium scanning, and coronary revasculariza-tion. J Am Coll Cardiol 2004;44:569-575.
42. McFalls EO, Ward HB, Moritz TE, et al: Coronary-artery revas-cularization before elective major vascular surgery. N Engl J Med 2004;351:2795-2804.
43. Landesberg G, Mosseri M, Fleisher LA: Coronary revasculariza-tion before vascular surgery. N Engl J Med 2005;352: 1492-1495.
44. Brilakis ES, Orford JL, Fasseas P, et al: Outcome of patients undergoing balloon angioplasty in the two months prior to noncardiac surgery. Am J Cardiol 2005;96:512-514.
45. Collet JP, Montalescot G, Blanchet B, et al: Impact of prior use or recent withdrawal of oral antiplatelet agents on acute coronary syndromes. Circulation 2004;110:2361-2367.
46. McFadden EP, Stabile E, Regar E, et al: Late thrombosis in drug-eluting coronary stents after discontinuation of anti-platelet therapy. Lancet 2004;364:1519-1521.
47. Ong AT, McFadden EP, Regar E, et al: Late Angiographic Stent Thrombosis (LAST) events with drug-eluting stents. J Am Coll Cardiol 2005;45:2088-2092.
48. Auer J, Berent R, Weber T, Eber B: Risk of noncardiac surgery in the months following placement of a drug-eluting coronary stent. J Am Coll Cardiol 2004;43:713.
49. Nasser M, Kapeliovich M, Markiewicz W: Late thrombosis of sirolimus-eluting stents following noncardiac surgery. Cath Cardiovasc Intervent 2005;65:516-519.
50. Murphy JT, Fahy BG: Thrombosis of sirolimus-eluting coronary stent in the postanesthesia care unit. Anesth Analg 2005;101:971-973.
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