Risks of Surgery in Patients With Coronary Stents
What are the incidence and type of cardiac and noncardiac surgery after percutaneous coronary intervention (PCI) and stenting during long-term follow-up, and what are predictors of periprocedural adverse ischemic and bleeding events?
This was a retrospective analysis of 39,362 consecutive patients undergoing PCI and stenting between July 2002 and December 2011, enrolled in the all-comers multicenter Registro regionale AngiopLastiche dell’Emilia-Romana (REAL) Registry. Cardiac risk associated with each surgical procedure was classified according to current European Society of Cardiology guidelines as low, intermediate, or high based on estimated 30-day cardiac event rates. Bleeding risk associated with each procedure was classified into low, intermediate, or high. Stent thrombosis risk associated with previous stenting was categorized based on the type of stent implanted and time between index PCI and surgery. Primary outcome was the incidence of cardiovascular death, myocardial infarction (MI), and serious bleeding event at 30 days.
During follow-up after PCI, a total of 13,128 patients underwent 17,226 surgical procedures. The cumulative incidence of any surgery at 30 days, 6 months, 1 year, and 5 years was 3.6%, 9.4%, 14.3%, and 40.0%, respectively. Thrombotic risk was independently associated with periprocedural cardiac death/MI (odds ratio [OR] = 1.50 for intermediate risk and 2.17 for high risk), whereas surgical risk and bleeding risk were not. Old-generation drug-eluting stent (Cypher and Cypher Select, Taxus Express and Taxus Liberte, and Endeavor with PC Polymer) was associated with an increased risk of ischemic events at any time point (0-180 days from PCI, OR, 2.10; 6-12 months OR, 1.90; >12 months OR, 1.45). Although bare-metal stent and new-generation drug-eluting stent were not significantly different >12 months and between 6-12 months after PCI, new-generation drug-eluting stents were safer between 0 and 180 days.
Approximately 14% of patients who received coronary stents underwent surgery during the first year after the procedure, and perioperative ischemic risk is inversely related with time from PCI to surgery and is influenced by stent type.
Though limited by its retrospective design, this is an important study, which establishes that the incidence of noncardiac surgery after PCI may be higher than has traditionally been reported. The authors re-focus perioperative risk management to an integrated approach that includes consideration of ischemic risk, thrombotic risk, and bleeding risk. As the authors opine and as is accepted, there is a ‘need for dedicated pharmacological strategies aimed at minimizing both ischemic and bleeding risk in patients with coronary stents undergoing surgery.’
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