When should aspirin (acetylsalicylic acid) be held in a patient with a stent who is undergoing an appendectomy?

Management of Aspirin in Patients with Coronary Stents Undergoing Appendectomy

For patients with coronary stents undergoing appendectomy, aspirin should be maintained throughout the perioperative period whenever possible, while clopidogrel may be discontinued 5 days before surgery and resumed as soon as possible postoperatively. 1

Risk Assessment Framework

Stent Thrombosis Risk Factors

• Time since stent placement (highest risk <6 months for drug-eluting stents) 1
• Type of stent (drug-eluting stents have higher thrombotic risk than bare-metal stents) 2
• Patient-specific factors increasing thrombosis risk:
  • History of stent thrombosis 1
  • Multiple stents, long stents, or stents at bifurcations 1
  • Incomplete revascularization 1
  • Diabetes or low ejection fraction 1

Bleeding Risk Assessment for Appendectomy

• Appendectomy typically represents an intermediate bleeding risk surgery 1
• Not considered a closed-space procedure (unlike intracranial, spinal, or posterior chamber eye surgery) 3

Management Algorithm

For Drug-Eluting Stents (DES)

• If <6-12 months since DES placement:

  • Ideally postpone elective surgery until after this period 1
  • If surgery cannot be delayed (as with appendectomy):
    • Maintain aspirin throughout perioperative period 1, 2
    • Discontinue clopidogrel 5 days before surgery 1
    • Resume clopidogrel as soon as possible after surgery, consider 300mg loading dose 1

• If >12 months since DES placement:

  • Maintain aspirin throughout perioperative period 1, 2
  • Discontinue clopidogrel 5 days before surgery 1, 4
  • Resume clopidogrel within 24 hours postoperatively 3

For Bare-Metal Stents (BMS)

• If <4-6 weeks since BMS placement:

  • Postpone surgery if possible 1
  • If emergency appendectomy is required, maintain both aspirin and clopidogrel 1, 3

• If >4-6 weeks since BMS placement:

  • Maintain aspirin throughout perioperative period 1, 5
  • Discontinue clopidogrel 5 days before surgery 4, 6
  • Resume clopidogrel within 24 hours postoperatively 3

Important Considerations

• Bleeding time normalizes within 96 hours after stopping aspirin, with complete platelet function recovery by 144 hours (6 days) 4
• The risk of stent thrombosis from discontinuing antiplatelet therapy generally outweighs the risk of surgical bleeding from continuing aspirin 3, 5
• Substituting antiplatelet agents with heparin or low-molecular-weight heparin does not adequately protect against stent thrombosis 1, 3
• A multidisciplinary approach involving the surgeon, anesthesiologist, and cardiologist is essential for optimal management 1

Common Pitfalls to Avoid

• Discontinuing both aspirin and clopidogrel simultaneously in patients with recent stent placement (increases thrombosis risk significantly) 1, 2
• Delaying resumption of antiplatelet therapy postoperatively (should be restarted within 24 hours when possible) 3, 7
• Failing to consider the specific type of stent and time since placement when making management decisions 1, 2
• Substituting antiplatelet therapy with anticoagulants, which do not provide adequate protection against stent thrombosis 1, 3