From the Guidelines
It is recommended to continue aspirin therapy indefinitely after carotid endarterectomy (CEA) and not discontinue it for cataract surgery, due to the high risk of thromboembolic events, as suggested by the 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline 1. When considering the management of antithrombotic therapy in patients with a history of cerebrovascular disease, such as those who have undergone CEA, the decision to discontinue aspirin should be made with caution.
- The risk of bleeding during cataract surgery must be weighed against the risk of stroke or other vascular events in post-CEA patients.
- According to the 2021 ACC expert consensus decision pathway, for patients who have undergone recent carotid endarterectomy, it is recommended to stop all antiplatelet therapy (APT) and treat with an oral anticoagulant (OAC) alone when considered safe from the risk of post-operative bleeding, typically 3 to 14 days after surgery 1. However, this guideline is more focused on the management of anticoagulant and antiplatelet therapy in patients with atrial fibrillation or venous thromboembolism undergoing percutaneous coronary intervention or with atherosclerotic cardiovascular disease, rather than specifically addressing the timing of aspirin discontinuation for cataract surgery after CEA.
- In the context of cataract surgery, the risk of bleeding is generally low, and the benefits of continuing aspirin therapy to prevent thromboembolic events may outweigh the risks.
- Aspirin should not be discontinued for cataract surgery in patients who have undergone CEA, unless there are compelling reasons to do so, and even then, it should be held for no more than 3-7 days before surgery and resumed as soon as possible afterward, ideally within 24 hours, as suggested by the example answer. The decision to discontinue aspirin should always involve consultation between the vascular surgeon who performed the CEA, the ophthalmologist performing cataract surgery, and potentially a cardiologist if the patient has additional cardiovascular risk factors.
From the Research
Aspirin Management After Carotid Endarterectomy for Cataract Surgery
- The decision to hold aspirin pre-operatively for cataract surgery after carotid endarterectomy surgery should be based on the individual patient's risk factors and medical history.
- According to 2, low-dose aspirin should be continued throughout the perioperative period for carotid endarterectomy, and there is no evidence that higher doses confer additional benefit.
- However, 3 suggests that the anti-platelet effect of aspirin is substantially reduced after administration of heparin during carotid endarterectomy, which may increase the risk of thromboembolic events.
- For cataract surgery, 4 and 5 recommend continuing aspirin, as the risk of bleeding complications is low, and the benefits of continuing antiplatelet therapy outweigh the risks.
- There is no specific guideline on the exact timing of when to hold aspirin after carotid endarterectomy for cataract surgery, but 6 suggests that clopidogrel use within 5 days of carotid endarterectomy may increase the risk of postoperative neck hematomas.
Considerations for Aspirin Management
- The patient's individual risk factors, such as cardiovascular disease and stroke risk, should be taken into account when deciding whether to hold aspirin.
- The type and dose of antiplatelet therapy, as well as the use of other medications, such as heparin and clopidogrel, should be considered.
- The surgeon and anesthesiologist should be aware of the patient's medication regimen and make informed decisions about perioperative management.
- Close monitoring of the patient's condition and laboratory values, such as platelet count and international normalized ratio, is essential to minimize the risk of complications.