Why the study?
Performing emergent spinal surgery within 6 months of DES placement is complex due to balancing spinal bleeding risks against stent thrombosis from DAPT interruption, with few studies documenting management.
How should perioperative dual antiplatelet therapy be managed in patients requiring urgent spinal surgery within 6 months of drug-eluting stent placement?
How should perioperative dual antiplatelet therapy be managed in patients requiring urgent spinal surgery within 6 months of drug-eluting stent placement?
A novel perioperative DAPT bridging protocol is proposed for the challenging scenario of patients needing urgent spine surgery within 6 months of DES placement.
Urgent spine surgery after DES warrants caution on timing; leaves open optimal DAPT management, requiring prospective validation.
BACKGROUND: Performing emergent spinal surgery within 6 months of percutaneous placement of drug-eluting coronary stent (DES) is complex. The risks of spinal bleeding in a "closed space" must be compared with the risks of stent thrombosis or major cardiac event from dual antiplatelet therapy (DAPT) interruption. METHODS: Eighty relevant English language papers published in PubMed were reviewed in detail. RESULTS: Variables considered regarding surgery in patients on DAPT for DES included: (1) surgical indications, (2) percutaneous cardiac intervention (PCI) type (balloon angioplasty vs. stenting), (3) stent type (drug-eluting vs. balloon mechanical stent), and (4) PCI to noncardiac surgery interval. The highest complication rate was observed within 6 weeks of stent placement, this corresponds to the endothelialization phase. Few studies document how to manage patients with critical spinal disease warranting operative intervention within 6 months of their PCI for DES placement. CONCLUSION: The treatment of patients requiring urgent or emergent spinal surgery within 6 months of undergoing a PCI for DES placement is challenging. As early interruption of DAPT may have catastrophic consequences, we hereby proposed a novel protocol involving stopping clopidogrel 5 days before and aspirin 3 days before spinal surgery, and bridging the interval with a reversible P2Y12 inhibitor until surgery. Moreover, postoperatively, aspirin could be started on postoperative day 1 and clopidogrel on day 2. Nevertheless, this treatment strategy may not be appropriate for all patients, and multidisciplinary approval of perioperative antiplatelet therapy management protocols is essential.
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Peeters et al. (2021) studied this question.
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