What is the recommended waiting period for non-cardiac surgery after Drug-Eluting Stent (DES) or Bare-Metal Stent (BMS) placement?

Timing of Non-Cardiac Surgery After Coronary Stent Placement

Elective non-cardiac surgery should be delayed for at least 30 days after bare-metal stent (BMS) implantation and optimally 6 months after drug-eluting stent (DES) implantation, with longer delays (12 months) recommended for DES placed for acute coronary syndrome. 1

Recommended Waiting Periods Based on Stent Type

Drug-Eluting Stents (DES)

• For DES placed for chronic coronary disease: Wait at least 6 months before elective non-cardiac surgery 1
• For DES placed for acute coronary syndrome: Wait at least 12 months before elective non-cardiac surgery 1
• For time-sensitive surgery with DES: May consider surgery after 3 months if the risk of delaying surgery outweighs the risk of stent thrombosis 1
• Contraindication: Elective surgery within 30 days of DES placement is potentially harmful due to high risk of stent thrombosis 1

Bare-Metal Stents (BMS)

• Minimum waiting period: At least 30 days 1
• Optimal waiting period: 3 months 1
• Contraindication: Elective surgery within 30 days of BMS placement is potentially harmful 1

Risk Stratification and Timing Considerations

The risk of major adverse cardiac events (MACE) following non-cardiac surgery is inversely related to the time interval between stent placement and surgery:

• Highest risk period:

  • First 30 days after any stent placement (MACE rates: 50% for BMS, 35% for DES) 2
  • Risk of stent thrombosis is greatest in the first 4-6 weeks post-PCI 1

• Intermediate risk period:

  • 30 days to 3 months (MACE rates: 14% for BMS, 13% for DES) 2
  • 3 to 6 months for DES (MACE rate: 15%) 2

• Lower risk period:

  • 3 months for BMS (MACE rate: 4%) 2

  • 6 months for DES (MACE rates: 6% for 6-12 months, 9% for >12 months) 2

Perioperative Antiplatelet Management

• Aspirin: Continue aspirin (75-100 mg) perioperatively if possible 1
• P2Y12 inhibitors (clopidogrel, ticagrelor, prasugrel):
  • If surgery occurs within high-risk period (<30 days for BMS, <3 months for DES), continue dual antiplatelet therapy (DAPT) unless bleeding risk is prohibitive 1
  • If P2Y12 inhibitor must be discontinued, stop 5 days before surgery for clopidogrel/ticagrelor (7 days for prasugrel) 1
  • Restart P2Y12 inhibitor as soon as possible after surgery 1

Special Considerations

• Higher risk scenarios requiring longer delays:

  • Complex PCI procedures (bifurcation stents, multiple stents, long stents) 3
  • Stent placement for acute myocardial infarction 1, 3
  • History of myocardial infarction within 6 months of surgery 4

• Emergency surgery considerations:

  • For urgent/emergent surgery that cannot be delayed, continue DAPT if possible 1
  • If within high-risk period and antiplatelet therapy must be discontinued, consider intravenous antiplatelet bridging 1
  • Multidisciplinary decision-making between cardiology, surgery, and anesthesiology is essential 3

Common Pitfalls to Avoid

• Premature discontinuation of DAPT is one of the strongest risk factors for stent thrombosis, which carries a mortality rate up to 45% 3
• Overestimating bleeding risk versus thrombotic risk, especially in the early post-stent period
• Failing to recognize that the indication for stenting (ACS vs. stable CAD) affects the required duration of DAPT and timing of surgery
• Assuming all DES are the same - newer-generation DES may have lower thrombotic risk than first-generation DES 1

The evidence clearly demonstrates that the risk of perioperative MACE decreases with longer intervals between stent placement and surgery, with the most dramatic risk reduction occurring after 3-6 months, depending on stent type and indication.