The impact of noncardiac surgery on selection of a revascularization strategy

The high incidence (22%) in the need for noncardiac surgery over the next 3 years after percutaneous coronary intervention (PCI) with a DES; and The low incidence of stent thrombosis related to noncardiac surgery after DES implantation and the fact that the overall complication rate does not seem to change significantly over time. It is important to appreciate the magnitude of the need for noncardiac surgery in this age population after DES implantation. The interventionalist should be particularly concerned for patients who may be at higher risk of stent thrombosis focusing on both the predicted and unpredicted need for possible interruption of dual antiplatelet therapy (DAPT) by attention to a detailed clinical history. There was no change in the incidence of complications over time. This is in contradistinction to traditional understanding suggesting that delayed endothelialization with DES implantation is responsible for the higher earlier event rate, particularly when DAPT is interrupted. In fact, current guidelines suggest that if noncardiac surgery is planned, the interventionalist should consider bare metal stent instead of DES implantation [2], coronary artery bypass surgery, or medical therapy. The higher potential incidence of a cardiac event in patients undergoing stent implantation for “off-label” indications; and That newer, second generation DES may act even more favorably in this patient population. The recent introduction of increasingly safer polymers potentially may release some of the constraints that interventionalists have faced with DES selection. Recent studies demonstrating that interruption of DAPT with Endeavor (Medtronic, Minneapolis, MN) [3] and Xience (Abbott Vascular, Abbott Park, IL) [4] stents suggest increasing safety in these newer generation stents when there is a need for DAPT interruption. Avoid over zealous “off label” indications for DES implantation; Consider the use of DES platforms based not only on efficacy but also the ability to tolerate unanticipated DAPT interruption; Delay surgery for at least 6 months after DES implantation if at all possible; Continue DAPT if surgery is needed and the bleeding risk is acceptable; and Continue aspirin and restart P2Y12 inhibitor as soon as possible if bleeding risk is high.