Which surgeries require discontinuing Plavix (clopidogrel)?

Which Surgeries Require Discontinuing Plavix (Clopidogrel)

Clopidogrel should be discontinued 5 days before surgeries with moderate-to-high bleeding risk where even minor bleeding would be catastrophic or unacceptable, specifically intracranial neurosurgery, spinal surgery within the medullary canal, posterior chamber eye surgery, and procedures with major tissue resection or wide dissections. 1

High-Risk Surgeries Requiring Discontinuation

The following procedures require clopidogrel discontinuation due to unacceptable bleeding consequences:

• Intracranial neurosurgery - bleeding in closed cranial space is catastrophic 1, 2
• Spinal surgery in the medullary canal - epidural hematoma can cause permanent neurological damage 1, 2
• Posterior chamber eye surgery - minor bleeding causes vision loss 1, 2
• Major tissue resection or wide dissection procedures - includes certain liver and thoracic surgeries 1
• Certain urologic procedures when alternative techniques cannot be used 1

For these procedures, discontinue clopidogrel at least 5 days before surgery to allow approximately 50-70% platelet function recovery. 1, 2, 3

Moderate-Risk Surgeries (Can Proceed on Aspirin Alone)

Most surgical procedures fall into this category and can be performed safely if clopidogrel is stopped but aspirin is continued: 1

• General abdominal surgery
• Orthopedic procedures (joint replacements, fracture repairs)
• Most thoracic procedures
• Most vascular surgery procedures
• Cardiac surgery (CABG) - stop clopidogrel 5 days prior but continue aspirin 1

Key principle: After coronary stent implantation, elective surgery requiring P2Y12 inhibitor discontinuation should be delayed until at least 1 month post-stent if aspirin can be maintained perioperatively. 1

Low-Risk Surgeries (Continue Clopidogrel)

These procedures can proceed without stopping clopidogrel (dual antiplatelet therapy can continue): 1, 2, 4

• All dental procedures including extractions and periodontal surgery 2, 4
• Cataract surgery 1
• Urethrocystoscopy 1
• Diagnostic gastrointestinal endoscopy with or without biopsies 1
• ERCP without sphincterotomy 1
• Colonic polypectomies <1 cm 1
• Minor dermatologic procedures 2
• Superficial peripheral nerve blocks (femoral, axillary, popliteal) 1

Use local hemostatic measures (gelatin sponges, sutures, tranexamic acid) to control any minor bleeding. 2, 4

Critical Timing Considerations

Within 1 month of stent placement: It is explicitly not recommended to discontinue dual antiplatelet therapy for elective surgery, regardless of stent type (bare metal or drug-eluting). 1, 2 The thrombotic risk overwhelms bleeding concerns.

1-6 months post-stent or recent MI: Surgery should ideally be postponed up to 6 months if possible. 1 If surgery cannot be delayed, stop only clopidogrel (keep aspirin) and perform surgery in hospitals with 24/7 catheterization laboratory availability. 1

Beyond 6 months post-stent in stable CAD: Clopidogrel can be discontinued 5 days before moderate-to-high bleeding risk procedures. 1

Resumption Protocol

Resume clopidogrel within 24-48 hours after surgery once hemostasis is achieved, given the substantial thrombotic hazard from lack of platelet inhibition. 1, 2, 5 A loading dose (300-600 mg) achieves maximal effect within 12-15 hours if rapid antiplatelet effect is needed. 2

Common Pitfalls to Avoid

• Do not stop both aspirin and clopidogrel unless absolutely required for closed-space surgery - the thrombotic risk is catastrophic (hazard ratio 161 for death/MI, 40% mortality with stent thrombosis). 4
• Do not routinely use platelet function testing to guide timing - it is not recommended and does not improve outcomes. 2
• Do not use bridging therapy with glycoprotein IIb/IIIa inhibitors, cangrelor, or LMWH routinely - reserve only for highly selected high-risk patients. 2
• Do not use LMWH as aspirin substitute - it promotes bleeding, is difficult to reverse, and is less effective at preventing thrombosis. 6

Decision Algorithm

1. Classify bleeding risk of the procedure (high/moderate/low) 1
2. Determine thrombotic risk: Recent stent (<1 month = absolute contraindication to stop DAPT; 1-6 months = high risk; >6 months = lower risk) 1, 5
3. For high bleeding-risk procedures: Stop clopidogrel 5 days before, continue aspirin if possible 1, 2
4. For moderate bleeding-risk procedures: Stop clopidogrel 5 days before if >6 months post-stent, continue aspirin 1
5. For low bleeding-risk procedures: Continue both agents, use local hemostatic measures 1, 2
6. Resume clopidogrel within 24-48 hours post-operatively 1, 2, 5