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The Big Heart Disease Lie

Cardiovascular Disease Causes and Possible Treatments

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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).

PCI deemed

Surgery necessary within 2 weeks

Balloon angioplasty

- 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.

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