What is the recommended preoperative risk assessment for noncardiac surgery in patients who have undergone stenting and balloon angioplasty, specifically regarding the timing of surgery relative to Dual Antiplatelet Therapy (DAPT)?

Preoperative Risk Assessment for Noncardiac Surgery After Stenting and Balloon Angioplasty

Noncardiac surgery should be delayed after PCI for at least 14 days following balloon angioplasty, 30 days after bare-metal stent (BMS) implantation, and optimally 365 days after drug-eluting stent (DES) implantation to minimize perioperative cardiac complications. 1

Timing of Surgery Based on Coronary Intervention Type

Balloon Angioplasty

• Minimum delay: 14 days after procedure 1
• Rationale: Arterial recoil or acute thrombosis is most likely within hours to days after angioplasty 1
• Risk of restenosis increases if surgery is delayed beyond 8 weeks 1
• Continue aspirin perioperatively if possible 1

Bare-Metal Stents (BMS)

• Minimum delay: 30 days after implantation 1
• Optimal window: 46-180 days after implantation 2
• Stent thrombosis risk is highest in first 2 weeks (up to 50% MACE rate if surgery performed <30 days) 3
• Risk decreases significantly after 30-45 days when endothelialization is more complete 1

Drug-Eluting Stents (DES)

• Optimal delay: 365 days after implantation 1
• Minimum acceptable delay: 180 days if risk of delaying surgery outweighs stent thrombosis risk 1
• MACE rates decrease significantly after 6 months (from 15% at 3-6 months to 6-9% after 6 months) 3
• Even after 6 months, some risk of stent thrombosis remains 4

Dual Antiplatelet Therapy (DAPT) Management

General Principles

1. Continue DAPT during perioperative period whenever possible, especially for:

   • Recent stent placement
   • High-risk stent locations (left main, multivessel, only remaining coronary artery)
   • History of previous stent thrombosis 1

2. If DAPT must be interrupted:

   • Continue aspirin if at all possible 1
   • Restart thienopyridine (clopidogrel, ticagrelor, prasugrel) as soon as possible after surgery 1
   • Consider risks of bleeding versus thrombosis for each specific case 1

3. Absolute contraindications to surgery:

   • Within 30 days of BMS implantation if DAPT must be discontinued 1
   • Within 12 months of DES implantation if DAPT must be discontinued 1
   • Within 14 days of balloon angioplasty if aspirin must be discontinued 1

Risk Assessment Algorithm

1. Determine type and timing of coronary intervention:

   • Balloon angioplasty, BMS, or DES
   • Time elapsed since procedure

2. Assess bleeding risk of planned surgery:

   • Low bleeding risk (can continue DAPT): Most dental procedures 1
   • High bleeding risk (may require antiplatelet modification): Neurosurgery, spinal surgery

3. Evaluate patient-specific thrombotic risk factors:

   • Left main stenting
   • Multivessel stenting
   • Prior stent thrombosis
   • Stent in only remaining coronary artery/graft conduit 1

4. Decision pathway:

   • If time since intervention < minimum recommended delay → postpone surgery if possible
   • If surgery urgent/cannot be delayed → consensus decision among treating clinicians regarding antiplatelet management 1
   • If optimal delay period has passed → proceed with surgery, continuing aspirin if possible

Common Pitfalls and Caveats

1. Discontinuation of DAPT does not guarantee safety even when surgery is performed after recommended delays 4

2. Continuation of DAPT does not provide complete protection against perioperative cardiac events (55% of patients who experienced MACE were on DAPT) 3

3. Bleeding risk with DAPT is significantly higher than with single antiplatelet therapy (21% vs. 4%) 3

4. Special consideration for intracoronary brachytherapy: Patients who received radiation treatment for in-stent restenosis have delayed healing and require longer antiplatelet therapy 1

5. Vigilance is required even beyond 365 days after DES placement due to reports of very late stent thrombosis 1

6. Drug-coated balloon angioplasty: May require shorter DAPT duration (1 month) compared to stents, making it potentially safer for patients at high bleeding risk who need surgery 5, 6