How long after femoral artery stent placement can Plavix (clopidogrel) be safely held in a patient?

Duration of Dual Antiplatelet Therapy After Femoral Artery Stent

For femoral artery stents, Plavix (clopidogrel) should be continued for at least 12 months after stent placement and should not be held during this period unless bleeding risk clearly outweighs thrombotic risk. 1

Minimum Duration Requirements

The duration before safely holding Plavix depends on the stent type placed in the femoral artery:

Bare Metal Stents

• Absolute minimum: 1 month of dual antiplatelet therapy (clopidogrel + aspirin) 1
• Ideal duration: 12 months for optimal protection against stent thrombosis 1
• High bleeding risk patients: 2 weeks minimum before considering discontinuation 1

Drug-Eluting Stents

• Sirolimus-eluting stents: Minimum 3 months, ideally extended to 12 months 1
• Paclitaxel-eluting stents: Minimum 6 months, ideally extended to 12 months 1
• Newer generation drug-eluting stents: Minimum 12 months 1
• High bleeding risk patients: 3-6 months minimum depending on specific stent type 1

After Completing Dual Antiplatelet Therapy

Once the minimum duration is completed:

• Aspirin must be continued indefinitely at 75-162 mg daily (or 81 mg for long-term use to reduce bleeding risk) 1
• Clopidogrel can be discontinued after the recommended duration is met 1

Critical Considerations Before Holding Plavix

Risk-Benefit Assessment

• If bleeding risk outweighs thrombotic benefit, earlier discontinuation may be reasonable, but this requires careful clinical judgment 1
• The risk of stent thrombosis leading to limb ischemia, myocardial infarction, or death must be weighed against bleeding complications 2

For Surgical Procedures

• Elective surgery should be deferred until the patient completes the appropriate course of dual antiplatelet therapy 2
• If surgery cannot be delayed: Continue aspirin if at all possible, and restart clopidogrel as soon as feasible postoperatively (within 12-24 hours) 2, 3
• The thrombotic risk from withdrawing antiplatelet drugs typically exceeds the surgical bleeding risk in most procedures 3

Common Pitfalls and Caveats

Premature Discontinuation

• Stopping Plavix early is the most significant risk factor for stent thrombosis, which can be catastrophic in peripheral arterial disease 2
• Early discontinuation within the first 6 months after drug-eluting stent placement dramatically increases thrombotic risk (hazard ratio 13.74) 4

Patient Counseling

• Patients must be counseled before stent placement about the critical importance of completing the full course of dual antiplatelet therapy 1
• Patients should never discontinue Plavix without discussing with their cardiologist or vascular specialist 1

Extended Vigilance

• The risk of late stent thrombosis extends beyond traditional recommended durations, particularly with drug-eluting stents 2
• Clinicians should remain vigilant even after 12 months, as thrombotic events can occur later 2

Practical Algorithm

1. Identify stent type (bare metal vs. drug-eluting, and specific drug if DES)
2. Calculate time since stent placement
3. Assess bleeding risk (history of GI bleeding, need for anticoagulation, planned surgery)
4. Apply minimum duration:
   • BMS: 1 month (2 weeks if high bleeding risk)
   • Sirolimus-DES: 3 months
   • Paclitaxel-DES: 6 months
   • Newer DES: 12 months
5. If within minimum duration: Do not hold Plavix unless life-threatening bleeding occurs
6. If beyond minimum duration: Consider extending to 12 months unless bleeding risk is prohibitive
7. After discontinuing Plavix: Continue aspirin indefinitely 1