Should a patient with recent bilateral leg stents continue dual antiplatelet therapy (DAPT) during surgery?

From the Guidelines

Patients with recent bilateral leg stents should generally continue at least one antiplatelet medication during surgery, with aspirin being the preferred choice to continue perioperatively if the bleeding risk allows, as recommended by the 2018 ESC/EACTS guidelines 1. The decision to continue or discontinue dual antiplatelet therapy (DAPT) in patients with recent bilateral leg stents undergoing surgery requires careful consideration of both bleeding and thrombotic risks.

• For most non-cardiac surgeries, aspirin (81-100 mg daily) should be continued while the P2Y12 inhibitor (clopidogrel 75 mg daily, ticagrelor 90 mg twice daily, or prasugrel 10 mg daily) may be temporarily discontinued if bleeding risk is high, as suggested by the 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease 1.
• The timing of P2Y12 inhibitor discontinuation depends on the specific medication: clopidogrel and ticagrelor should be stopped 5-7 days before surgery, while prasugrel requires 7-10 days, according to the 2018 ESC/EACTS guidelines 1.
• For high thrombotic risk patients (stents placed within the last 3-6 months), delaying elective surgery is preferable, as recommended by the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery 1.
• If surgery is urgent, maintaining DAPT perioperatively may be necessary despite increased bleeding risk, as suggested by the 2018 ESC/EACTS guidelines 1.
• After surgery, the P2Y12 inhibitor should be restarted as soon as hemostasis is achieved, typically within 24-48 hours, as recommended by the 2019 ESC/EACTS guidelines on myocardial revascularization 1. This approach balances the risk of stent thrombosis, which can lead to limb-threatening ischemia, against surgical bleeding complications.
• The final decision should involve a multidisciplinary discussion between the vascular specialist, surgeon, and anesthesiologist to develop an individualized perioperative antiplatelet strategy, as recommended by the 2018 ESC/EACTS guidelines 1.

From the FDA Drug Label

The PLATO protocol recommended a procedure for withholding study drug prior to CABG or other major surgery without unblinding If surgery was elective or non-urgent, study drug was interrupted temporarily, as follows: If local practice was to allow antiplatelet effects to dissipate before surgery, capsules (blinded clopidogrel) were withheld 5 days before surgery and tablets (blinded ticagrelor) were withheld for a minimum of 24 hours and a maximum of 72 hours before surgery If local practice was to perform surgery without waiting for dissipation of antiplatelet effects capsules and tablets were withheld 24 hours prior to surgery and use of aprotinin or other hemostatic agents was allowed If local practice was to use IPA monitoring to determine when surgery could be performed both the capsules and tablets were withheld at the same time and the usual monitoring procedures followed.

The decision to continue dual antiplatelet therapy (DAPT) during surgery for a patient with recent bilateral leg stents should be made on a case-by-case basis, considering the risk of bleeding versus the risk of stent thrombosis.

• Key considerations:
  • The timing of surgery relative to stent placement
  • The type of surgery and its associated bleeding risk
  • The patient's overall risk profile for bleeding and thrombotic events Based on the provided information from the PLATO study 2, it is recommended to withhold ticagrelor for a minimum of 24 hours and a maximum of 72 hours before surgery if local practice is to allow antiplatelet effects to dissipate before surgery. However, the final decision should be individualized and based on a thorough assessment of the patient's specific situation.

From the Research

Management of Dual Antiplatelet Therapy During Surgery

The decision to continue dual antiplatelet therapy (DAPT) during surgery for a patient with recent bilateral leg stents should be made after careful consideration of the risks of thrombosis and bleeding.

• The risks and benefits of continuing or discontinuing DAPT should be jointly assessed by the orthopedic surgeon and cardiologist 3.
• There is little data supporting a significantly increased bleeding risk associated with mortality in orthopedic patients when antiplatelet therapy is continued perioperatively 3.
• Premature withdrawal of dual antiplatelet therapy carries a substantial risk of stent thrombosis, as demonstrated by a case of simultaneous stent thrombosis in two coronary arteries following discontinuation of clopidogrel for an elective noncardiac surgery 4.

Duration of Dual Antiplatelet Therapy

The optimal duration of DAPT after coronary stent placement or acute coronary syndrome can be customized based on individual patient characteristics, such as age, renal function, comorbidities, and hemorrhagic history 5.

• A 6-month DAPT, or even less, may provide a good compromise between hemorrhagic risk and ischemic recurrences in patients at high risk of bleeding 5.
• Continued treatment with thienopyridine beyond 1 year after placement of a drug-eluting stent significantly reduced the risks of stent thrombosis and major adverse cardiovascular and cerebrovascular events, but was associated with an increased risk of bleeding 6.

Perioperative Considerations

Perioperative continuation of dual antiplatelet therapy is associated with an increased risk of bleeding, particularly in patients treated with new potent drugs such as prasugrel and ticagrelor 7.

• Platelet function monitoring may be considered to safely shorten the preoperative waiting period, assess the risk of bleeding and transfusion, and initiate specific therapy in bleeding patients 7.