Should one hold Clopidogrel (Plavix) prior to placement of a vagal nerve stimulator?

From the Guidelines

Yes, Clopidogrel (Plavix) should typically be held prior to vagal nerve stimulator placement to minimize the risk of bleeding complications. The most recent and highest quality evidence suggests that discontinuing Clopidogrel at least 5 days before surgery is recommended to reduce major bleeding complications 1. This guideline is based on the management of patients undergoing coronary artery bypass graft (CABG) surgery, but the principle of minimizing bleeding risk by discontinuing antiplatelet agents like Clopidogrel can be applied to other surgical procedures, including vagal nerve stimulator placement. Some key points to consider include:

• Discontinuing Clopidogrel 5-7 days before the surgical procedure allows for the restoration of normal platelet function, as Clopidogrel irreversibly inhibits platelet aggregation by blocking the P2Y12 receptor.
• For patients with high thrombotic risk, such as those with recent coronary stents, consultation with the patient's cardiologist is essential to develop a bridging strategy, which might include temporary use of shorter-acting antiplatelet agents or low molecular weight heparin.
• After the procedure, Clopidogrel can usually be resumed within 24-48 hours once adequate hemostasis is achieved and with surgeon approval.
• The decision to hold Clopidogrel must always balance the risk of surgical bleeding against the risk of thrombotic events, particularly in patients with recent coronary interventions or history of stroke, and should be made collaboratively between the neurosurgeon, anesthesiologist, and the physician managing the patient's cardiovascular care 1.

From the Research

Vagal Nerve Stimulation and Clopidogrel (Plavix)

There is no direct evidence in the provided studies regarding the management of Clopidogrel (Plavix) prior to the placement of a vagal nerve stimulator.

• The studies primarily focus on the indications, implantation techniques, and outcomes of vagal nerve stimulation therapy for patients with refractory epilepsy or treatment-resistant depression 2, 3, 4, 5, 6.
• They discuss various aspects such as surgical techniques, complications, and the effectiveness of vagal nerve stimulation in reducing seizure frequency and intensity 3, 4, 5, 6.
• However, none of the studies mention the use of Clopidogrel (Plavix) or provide guidance on whether it should be held prior to the placement of a vagal nerve stimulator.

Surgical Considerations

• The placement of a vagal nerve stimulator is a surgical procedure that involves implanting a device to electrically stimulate the vagus nerve 2, 4, 6.
• The procedure can be performed under general anesthesia or regional/local anesthesia, with the latter offering advantages such as continuity of anticonvulsant therapy and implantation in the outpatient setting 3.
• Complications related to the implantation of a vagal nerve stimulator can include hoarseness, throat pain/dysphagia, coughing, and shortness of breath, as well as surgical complications like postoperative infection, VNS-associated arrhythmias, and vocal cord paresis 2, 4, 5.

Lack of Direct Evidence

• Given the lack of direct evidence on the management of Clopidogrel (Plavix) prior to vagal nerve stimulator placement, it is essential to consider the broader context of perioperative management of anticoagulant and antiplatelet therapy in surgical procedures.
• However, this specific question cannot be answered based on the provided studies, as they do not address the use of Clopidogrel (Plavix) in the context of vagal nerve stimulator placement 2, 3, 4, 5, 6.