What is the recommended timing for non-emergent surgery after percutaneous coronary intervention (PCI) with a bare-metal stent or a drug-eluting stent?

Timing of Surgery After Percutaneous Coronary Intervention (PCI)

For non-emergent surgery after PCI, delay elective surgery for at least 30 days after bare-metal stent (BMS) placement and at least 6 months after drug-eluting stent (DES) placement for chronic coronary disease, extending to 12 months for DES placed for acute coronary syndrome. 1, 2

Recommended Timing Based on PCI Type

Balloon Angioplasty (without stent)

• Delay elective surgery for at least 14 days after balloon angioplasty to allow for healing of the vessel injury 1
• Continue daily aspirin therapy perioperatively when possible 1

Bare-Metal Stents (BMS)

• Delay elective surgery for at least 30 days (optimally 4-6 weeks) after BMS placement 1, 2
• Stent thrombosis risk is highest in the first 2 weeks and becomes exceedingly rare (<0.1%) after 4 weeks 1
• Premature discontinuation of dual antiplatelet therapy within 4 weeks of BMS implantation significantly increases risk of stent thrombosis 1

Drug-Eluting Stents (DES)

• For DES placed for chronic coronary disease: Delay elective surgery for at least 6 months 1, 2
• For DES placed for acute coronary syndrome: Delay elective surgery for at least 12 months 1, 2
• For complex DES-PCI (bifurcation stents, long stent lengths, multivessel PCI): Consider delaying surgery for 12 months 1
• Late stent thrombosis has been reported up to 1.5 years after DES implantation, particularly when antiplatelet therapy is discontinued 1

Perioperative Antiplatelet Management

For Patients with BMS

• Continue aspirin (75-100 mg) perioperatively if possible 1
• Thienopyridines (clopidogrel, ticlopidine) are generally administered for 4 weeks after BMS placement 1
• Consider a 1-week interval between thienopyridine discontinuation and surgery 1

For Patients with DES

• Continue aspirin perioperatively if possible 1
• For surgery within 6 months of DES placement, the risk of stent thrombosis with discontinuation of dual antiplatelet therapy outweighs the bleeding risk in most surgeries 1, 3
• If thienopyridine must be discontinued, restart as soon as possible after surgery 1

Risk Assessment

• Perioperative major adverse cardiac events (MACE) are highest within the first 6 months after PCI and stabilize at approximately 1% thereafter 1
• Risk factors for perioperative MACE include:
  • Advanced age 4
  • Emergency surgery 4
  • History of myocardial infarction 4
  • PCI performed for acute coronary syndrome 1
• Studies show an inverse relationship between the interval from PCI to surgery and perioperative MACE 3
• Even with continuation of dual antiplatelet therapy, complete protection against MACE is not guaranteed 3, 5

Special Considerations

• For time-sensitive surgery that cannot be delayed:
  • For DES placed <3 months ago: Consider bridging with intravenous antiplatelet therapy 1
  • For surgery within 30 days of BMS or within 3 months of DES: Continue dual antiplatelet therapy unless bleeding risk is prohibitive 2
• For high bleeding risk procedures:
  • Consider stopping clopidogrel 5 days before and aspirin 3 days before surgery 6
  • Restart aspirin on postoperative day 1 and clopidogrel on day 2 6

Decision Algorithm

1. Identify PCI type and timing:

   • Balloon angioplasty only: Delay surgery >14 days 1
   • BMS: Delay surgery >30 days 1, 2
   • DES for stable CAD: Delay surgery ≥6 months 1, 2
   • DES for ACS: Delay surgery ≥12 months 1, 2

2. If surgery cannot be delayed:

   • Continue aspirin if possible 1
   • Consider perioperative bridging for high thrombotic risk 1
   • Recognize increased risk of MACE when surgery is performed <30 days after DES implantation 7