What is the recommended management for a patient with a peripheral stent, specifically regarding dual antiplatelet therapy (DAPT)?

Management of Dual Antiplatelet Therapy (DAPT) for Peripheral Stents

For patients with peripheral stents, dual antiplatelet therapy (DAPT) should be maintained for at least 4-6 weeks after placement of a bare metal stent and at least 6-12 months after placement of a drug-eluting stent to reduce the risk of stent thrombosis. 1

Duration of DAPT Based on Stent Type

• Bare metal stents: DAPT (aspirin plus clopidogrel) should be maintained for at least 4-6 weeks 1
• Drug-eluting stents: DAPT should be maintained for at least 6-12 months 1
• After the initial mandatory period, long-term antiplatelet therapy should be considered as withdrawing antiplatelet agents is a major risk factor for thrombosis 1

Risk Factors for Stent Thrombosis

Patients at high risk for stent thrombosis include those with:

• Discontinuation of antiplatelet therapy within 6-12 months after stent placement 1
• History of previous stent thrombosis 1
• Multiple stents or long stents 1
• Stents placed at bifurcations 1
• Incomplete revascularization 1
• Diabetes mellitus 1
• Low ejection fraction 1

Perioperative Management for Patients Requiring Surgery

If a patient with a peripheral stent requires surgery during the critical period when DAPT is recommended:

• For minor procedures (dental, dermatologic, ophthalmologic):

  • Continue aspirin throughout the procedure 1
  • P2Y12 inhibitor (clopidogrel) may be interrupted if necessary 1

• For major procedures with high bleeding risk:

  • If possible, postpone elective surgery until completion of the recommended DAPT duration (6-12 months for drug-eluting stents) 1
  • If surgery cannot be postponed:
    • Maintain aspirin therapy throughout the perioperative period 1
    • Clopidogrel may be withdrawn for a 5-day window before surgery 1
    • Resume clopidogrel as soon as possible after surgery, preferably within 5 days 1
    • Consider a loading dose of 300 mg when resuming clopidogrel 1

Special Considerations

• For patients with drug-eluting stents who are within 3-12 months post-implantation and require elective surgery, stopping the P2Y12 inhibitor prior to surgery is suggested while continuing aspirin 1
• Routine bridging therapy with glycoprotein IIb/IIIa inhibitors, cangrelor, or LMWH is not recommended for most patients 1
• For high-risk patients (e.g., those with recent stent placement in a critical location), a multidisciplinary approach involving cardiologists, surgeons, and anesthesiologists should be employed to balance thrombotic and bleeding risks 1

Long-term Management

• Extended DAPT beyond 12 months may provide additional protection against stent thrombosis and major adverse cardiovascular events but increases bleeding risk 2
• The decision to continue DAPT beyond the recommended duration should consider the patient's individual risk factors for both thrombosis and bleeding 2
• If discontinuation of one antiplatelet agent is necessary after the mandatory period, maintaining at least aspirin therapy is recommended 1, 3

Important Caveats

• Premature discontinuation of DAPT significantly increases the risk of stent thrombosis, myocardial infarction, and death 4
• An elevated risk of stent thrombosis has been observed in the 3 months following discontinuation of thienopyridine treatment, even after the recommended DAPT duration 2
• For patients requiring future surgery, consider using bare metal stents rather than drug-eluting stents when initially placing the stent, if appropriate 1