Perioperative management of antiplatelet therapy in patients with drug-eluting stents

Significant advancements in percutaneous treatment of coronary artery disease have been achieved with the introduction of bare metal stents. They have two major drawbacks: acute/subacute stent thrombosis, successfully managed with antiplatelet therapy immediately after stent implantation; and in-stent restenosis, prevention of which has been achieved with the development of drug-eluting stents. Drug-eluting stents have become preferred therapy for patients undergoing coronary artery intervention, though reports of late stent thrombosis have led to uncertainty about the duration of antiplatelet therapy after drug-eluting stents placement. Much controversy remains regarding perioperative management of patients with these devices, presenting for surgery or other invasive procedures. The purpose of this review is to provide an overview of the changing culture of coronary artery stenting, in addition to discussing perioperative management strategies and controversies surrounding coronary stents and antiplatelet therapy. A comprehensive literature search of MEDLINE was conducted using as keywords: antiplatelet therapy, non-coronary surgery, drug-eluting stents, and stent thrombosis. There is no definite standard of care for the perioperative management of drug-eluting stents in patients with drug-eluting stents. However, there is a growing understanding of the importance of continuation of drug-eluting stents in the perioperative period in order to prevent stent thrombosis along with a concern about the possibility of increased bleeding. Appropriate timing of surgery after coronary artery stenting, team approach to the perioperative management of such patients with involvement of cardiologist, anesthesiologist, and surgeon, and development of an individual plan for each patient, weighing that patient's risk of thrombosis vs the risk of bleeding, could improve patient safety and optimize outcome.