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Characterization of Post-Operative Risk Associated With Prior Drug-Eluting Stent Use

Saif Anwaruddin, MD^_*, Arman T. Askari, MD^_*, Hammad Saudye, MD, Lilian Batizy, MS, Penny L. Houghtaling, MS, Mohammad Alamoudi, MD^||, Michael Militello, PharmD, Kamran Muhammad, MD^_*, Samir Kapadia, MD^_*, Stephen G. Ellis, MD^_*,_*

^_* Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio
Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
^|| Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, Missouri

^_* Reprint requests and correspondence: Dr. Stephen G. Ellis, Director, Sones Cardiac Catheterization Laboratory, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio 44195 (Email: elliss{at}ccf.org).

Objectives: The aim of this study was to assess risk of inpatient surgery at any time after percutaneous coronary intervention (PCI) with drug-eluting stents (DES).

Background: Risk of adverse events, including stent thrombosis (ST), in patients undergoing surgical procedures with prior DES remains poorly defined.

Methods: Outcomes of consecutive patients having inpatient surgical procedures after PCI with DES, placed from April 28, 2003 until December 31, 2006 at a tertiary-care medical center, were studied. Primary and secondary end points were 30-day post-operative risk of the Academic Research Consortium (ARC) definite and modified probable definitions of ST and combined 30-day post-operative risk of death, nonfatal myocardial infarction (MI), or ST, respectively. Multivariable logistic regression analyses were used to determine independent risk factors.

Results: Six hundred six inpatient surgeries on 481 patients with a mean time from PCI to surgery of 1.07 ± 0.89 years were evaluated. The primary and secondary end points occurred after 11 (2.0%) and 56 (9%) surgeries, respectively. Risk of the combined end point and ST decreased significantly in the first 1 to 6 months after PCI (p < 0.0001 and p < 0.014, respectively); however, risk persisted when time between PCI and surgery was >12 months. Independent correlates of the combined end point include emergency surgery, antecedent MI, the pre-operative use of intravenous heparin, and atherosclerotic lesion length treated with DES. Oral antiplatelet status at time of surgery was not a correlate of events.

Conclusions: Risk of 30-day post-operative adverse events, including ST, remains significantly higher when surgery is performed soon after PCI, while intermediate-term risk extending at least 2 to 3 years remains important.

Key Words: drug-eluting stents • perioperative risk • stent thrombosis

Abbreviations and Acronyms   ARC = Academic Research Consortium   BMS = bare-metal stent(s)   DES = drug-eluting stent(s)   MI = myocardial infarction   PCI = percutaneous coronary intervention   ST = stent thrombosis

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