title: Late and very late drug-eluting stent thrombosis in the immediate postoperative period after antiplatelet withdrawal: a retrospective study.
abstract: BACKGROUND
  Late (31-360 days after deployment) and very late (>360 days after deployment) stent thrombosis is a feared complication after drug-eluting stent (DES) deployment. The American College of Cardiology/American Heart Association guidelines recommend dual antiplatelet therapy for 12 months due to the lack of protection beyond this period in randomized trials. The perioperative period is a unique state of generalized hypercoagulability which can predispose people to DES thrombosis when combined with the rebound hypercoagulable effect of antiplatelet withdrawal.
  
  
  METHODS
  A retrospective chart review was performed to detect incidences of late and very late postoperative DES thrombosis after elective noncardiac surgery. Only definite and probable cases of stent thrombosis were included. All cases were analyzed for patient demographics, comorbidities, type of surgery, intervention history, preoperative antiplatelets management, postoperative course and outcome.
  
  
  RESULTS
  A total of six patients with prior DES deployment (10-42 months earlier, average 30 months) developed DES thrombosis (five very late and one late) in the immediate postoperative period. All patients had stable coronary artery disease and were cleared for surgery (intermediate cardiac risk surgery) by their cardiologist. In all patients, antiplatelets were discontinued 4-7 days (average 5.6 days) prior to surgery to minimize operative bleeding. Five of six patients developed ST-segment elevation myocardial infarction. Half of the patients had simultaneous two-vessel DES thrombosis and two cases had single vessel thrombosis. Three patients developed ventricular fibrillation and cardiac arrest. One-third of the patients died during the index hospitalization. Coronary thrombectomy and angioplasty was successful in the remaining four cases. The incidence of postoperative late and very late DES thrombosis among all patients undergoing noncardiac surgery who were older than 40 years was 0.006%.
  
  
  CONCLUSIONS
  Caution should be exercised when attempting to withdraw antiplatelets preoperatively in patients with DES even when the recommended 12-month period of dual antiplatelet therapy (DAPT) has elapsed. The significant morbidity and mortality of this complication warrants further research to study the ideal perioperative management of antiplatelets in patients with prior DES deployment over 1 year who are still receiving DAPT.
authors.affiliation: Internal Medicine Department, Mercy Medical Center, Clinton, IA 52732, USA hesham.omar@apogeephysicians.com.
authors.forename: Hesham R
authors.initials: HR
authors.lastname: Omar
authors.affiliation: Florida Gulf to Bay Anesthesiology Associates LLC, Tampa, FL, USA.
authors.forename: Collin
authors.initials: C
authors.lastname: Sprenker
authors.affiliation: Florida Gulf to Bay Anesthesiology Associates LLC, Tampa, FL, USA.
authors.forename: Rachel
authors.initials: R
authors.lastname: Karlnoski
authors.affiliation: Department of Surgery/Anesthesiology, Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, FL, USA.
authors.forename: Enrico M
authors.initials: EM
authors.lastname: Camporesi
authors.affiliation: Tampa General Hospital and Florida Gulf to Bay Anesthesiology Associates LLC, Tampa, FL, USA.
authors.forename: Devanand
authors.initials: D
authors.lastname: Mangar
mesh_terms: D000368:Aged; D003324:Coronary Artery Disease / Q000601:surgery; D003328:Coronary Thrombosis / Q000453:epidemiology* / Q000209:etiology / Q000517:prevention & control; D054855:Drug-Eluting Stents / Q000009:adverse effects*; D017558:Elective Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006323:Heart Arrest / Q000453:epidemiology / Q000209:etiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology / Q000209:etiology; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage* / Q000627:therapeutic use; D011184:Postoperative Period; D012189:Retrospective Studies; D013997:Time Factors; D014693:Ventricular Fibrillation / Q000453:epidemiology / Q000209:etiology
chemical_list: D010975:Platelet Aggregation Inhibitors
keywords: antiplatelet withdrawal; drug-eluting stent; stent thrombosis