Surgery Common, Safe After Coronary Stent Implantation

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In the 3 years following stent implantation, non-bypass surgery occurs in almost a quarter of patients and imparts few ischemic or bleeding complications, according to a large Japanese registry study published online March 6, 2012, ahead of print in Circulation: Cardiovascular Interventions. However, the report also finds that perioperative dual antiplatelet therapy does little to lower the risk of ischemic events.

Researchers led by Takeshi Kimura, MD, of the Kyoto University Graduate School of Medicine (Kyoto, Japan), looked at the non-CABG surgery rates during the 3 years after stent implantation in 12,207 patients in the CREDO-Kyoto (Coronary Revascularization Demonstrating Outcome Study in Kyoto) PCI/CABG registry Cohort-2. Slightly over half (55%) of the patients received DES (n = 6,802), with the remainder receiving BMS (n = 5,405).

The overall rate of surgical procedures was 22%, with DES patients undergoing more procedures than BMS patients both early (4.4% vs. 1.9% at 42 days) and late (23% vs. 21% at 3 years; P = 0.0007 throughout follow-up). Surgery types included vascular (15%), abdominal (15%), ophthalmic (12%), GI endoscopic (12%), oral/maxillofacial (9%), orthopedic (9%), and several other areas.

Complications Rare Irrespective of Stent Type

At 30 days, the rate of the composite ischemic outcome of death/MI/stent thrombosis was low at 3.2% and primarily driven by all-cause death (2.8%), while MI and definite/probable stent thrombosis were also low at 0.6% and 0.4%, respectively. The GUSTO moderate/severe bleeding rate, meanwhile, was only 2.6%. There were no significant differences in 30-day ischemic outcomes or post-surgical bleeding between the BMS and DES groups.

After adjusting for confounders, DES use relative to BMS use did not influence ischemic outcomes (HR 1.63; 95% CI 0.93-2.87; P = 0.09) or bleeding events (HR 0.6; 95% CI 0.34-1.06; P = 0.08), though trends were apparent.

At 1 year, discontinuation of thienopyridine therapy was higher in BMS patients, with 66% of DES patients continuing therapy compared with 23% of BMS patients (P < 0.0001). Slightly more than half of all patients had no antiplatelet therapy during surgery (53%), while the rest had either dual (27%) or single antiplatelet therapy (20%).

At 30 days, dual antiplatelet therapy was associated with higher rates of death/MI/stent thrombosis and bleeding compared with no or single antiplatelet therapy, but there was no difference in definite or probable stent thrombosis (table 1).

Table 1. Complications at 30 Days by Perioperative Antiplatelet Use

After adjustment, perioperative single antiplatelet therapy was associated with a strong trend for lower ischemic events (HR 0.4; 95% CI 0.13-1.01; P = 0.053) and similar bleeding risk (HR 0.59; 95% CI 0.22-1.42; P = 0.2) compared with dual antiplatelet therapy. The absence of perioperative antiplatelet therapy had no effect on risk compared with dual antiplatelet therapy with regard to ischemic events (HR 0.64; 95% CI 0.33-1.23; P = 0.2) or bleeding events (HR 0.64; 95% CI 0.33-1.27; P = 0.2).

“Surgical procedures were commonly performed after coronary stent implantation, and the risk of ischemic and bleeding complications in surgical procedures after DES was low, without any difference from that after BMS,” the researchers conclude. “Perioperative administration of dual [antiplatelet therapy] was not associated with lower risk for ischemic events.”

Stent, Antiplatelet Recommendations

The investigators report that BMS are preferred in patients deemed likely to require invasive or surgical procedures, demonstrated by the higher incidence of early surgical procedures in the BMS group. However, the high rate of surgical procedures that were not planned until after coronary stent implantation was unexpected as was the finding that 30-day bleeding was no different between the BMS and DES groups.

“According to these observations, choice of DES might be a reasonable option, even in patients who are likely to undergo surgical procedures, if risk of restenosis is expected to be high,” the authors note.

They also point out that perioperative thienopyridine administration was associated with higher bleeding risk, which may have contributed to the higher risk for ischemic events linked with dual antiplatelet therapy. “Therefore, it would be recommended to continue aspirin in most patients undergoing surgical procedures after coronary stent implantation except for those surgical procedures, such as intracranial surgery and spinal surgery, where serious clinical consequences are expected after bleeding,” Dr. Kimura and colleagues conclude.

 

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Source:
Tokushige A, Shiomi H, Morimoto T, et al. Incidence and outcome of surgical procedures after coronary bare-metal and drug-eluting stent implantation: A report from the CREDO-Kyoto PCI/CABG registry Cohort-2. Circ Cardiovasc Interv. 2012;Epub ahead of print.

 

 

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