When should Plavix (clopidogrel) and aspirin be stopped before trigger finger surgery under local anesthesia?

Management of Aspirin and Clopidogrel Before Trigger Finger Surgery

For trigger finger surgery under local anesthesia, aspirin can be continued throughout the perioperative period, while clopidogrel should be discontinued 5 days before surgery.

Risk Assessment for Antiplatelet Management

Trigger finger surgery is considered a minor surgical procedure performed under local anesthesia with minimal bleeding risk. When managing antiplatelet therapy before this procedure, both bleeding risk and thrombotic risk must be carefully balanced:

Bleeding Risk Considerations

• Trigger finger surgery is a minor hand procedure with limited tissue dissection
• Local anesthesia allows for direct visualization and control of any bleeding
• The procedure does not involve surgery in closed spaces (like intracranial or spinal surgery)

Thrombotic Risk Considerations

• Patients on dual antiplatelet therapy typically have significant cardiovascular disease
• Discontinuation of antiplatelet agents increases risk of thrombotic events
• The American College of Chest Physicians (ACCP) recommends continuing aspirin for minor procedures 1

Specific Recommendations for Antiplatelet Management

Aspirin Management

• Continue aspirin throughout the perioperative period 1, 2
• The ACCP guidelines specifically recommend continuing aspirin for minor procedures rather than stopping it 7-10 days before surgery 1
• For patients taking aspirin for secondary prevention of cardiovascular disease, continuing aspirin during minor procedures is preferred 1, 2

Clopidogrel Management

• Discontinue clopidogrel 5 days before surgery 1, 3
• The French Working Group on Perioperative Haemostasis recommends stopping clopidogrel 5 days before surgery 1
• The FDA label for clopidogrel indicates that when possible, therapy should be interrupted for 5 days prior to surgery with major bleeding risk 3
• Clopidogrel irreversibly inhibits platelets for their lifespan (7-10 days), with normal function returning as new platelets are generated 3

Special Patient Considerations

Patients with Recent Coronary Stents

• For patients with recent coronary stent placement:
  • If possible, delay elective surgery until completion of the mandatory dual antiplatelet therapy period (at least 6 months after drug-eluting stent placement) 1
  • If surgery cannot be delayed, continue aspirin while stopping clopidogrel 5 days before surgery 1
  • For bare-metal stents, minimum 6 weeks of dual therapy is required 1

Patients at High Cardiovascular Risk

• For patients at moderate to high cardiovascular risk, continue aspirin throughout the perioperative period 1, 2
• For patients at low cardiovascular risk, stopping both agents may be considered 1

Resumption of Antiplatelet Therapy

• Resume clopidogrel within 24-48 hours after surgery once adequate hemostasis is achieved 3
• If clopidogrel was stopped, restart as soon as possible to minimize thrombotic risk 3

Practical Considerations for Surgery

• Inform the surgeon about the patient's antiplatelet regimen
• Ensure meticulous hemostasis during the procedure
• Consider having platelets available if excessive bleeding occurs during surgery while on clopidogrel 4
• The surgeon can check the adequacy of trigger finger release during the procedure by asking the patient to make a fist actively 5

By following these evidence-based recommendations, the risk of perioperative bleeding can be minimized while protecting patients from thrombotic events during this minor surgical procedure.