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• “Pro-healing” coronary stent before undeferrable major non-cardiac surgery.
  Federico Piscione
  Published on: 23 November 2015
• RE: Non-Cardiac Surgery and Anti-Platelet Therapy Following Coronary Artery Stenting
  Luca Carmignani
  Published on: 23 November 2015

• Published on: 23 November 2015

  “Pro-healing” coronary stent before undeferrable major non-cardiac surgery.

  • Federico Piscione, Associate Professor of Cardiology
  • Other Contributors:
    • Salvatore Cassese

  We read with great interest the work by Luckie et al., recently published in this Journal. (1) It's known that for patients who suffer from infiltrative, obstructive or bleeding carcinomas, or for high rupture risk aneurismal disease, a prompt surgical procedure may represent “survival”, and that in case of revascularization requirement, currently available options, either bare-metal or drug-eluting stent or plain-old ba...

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  We read with great interest the work by Luckie et al., recently published in this Journal. (1) It's known that for patients who suffer from infiltrative, obstructive or bleeding carcinomas, or for high rupture risk aneurismal disease, a prompt surgical procedure may represent “survival”, and that in case of revascularization requirement, currently available options, either bare-metal or drug-eluting stent or plain-old balloon angioplasty, might put back surgical procedure, according to the mandatory antiplatelet therapy time window. (2) In the section “Stents with pro-healing surfaces” of their manuscript, the Authors reported our preliminary data regarding a pilot study of percutaneous revascularization with a new type of “pro-healing” stent, followed by a short-term dual antiplatelet therapy, and subsequent urgent or life-saving surgery few days after stent deployment. Recently, we published as a full-length manuscript, (3) final data regarding 30 consecutive patients treated with this stenting strategy, with optimal acute procedural result. According to an average antiplatelet therapy time of 12.2±3.9 days, patients included underwent surgery 10 to 22 days after coronary stent deployment (average 17.2±3.9 days). No cardiac event has been reported in the perioperative period up to 30-days follow-up after surgery. Clearly, we did not randomize or match this population with a comparison group because it would not be possible to perform surgical procedure, as soon as we did. (2) Although based on a small sample size, our findings suggest that the “pro-healing” stent should be safe and feasible for patients candidate for upcoming major surgery who need a previous revascularization. Further registries are needed to confirm the safety and furthermore the mid- and long term efficacy of this stent that is racking up among interventional cardiologists, especially in this specific subset of patients. In this respect, we completely agree with Authors regarding the importance of a timely identification of patients who could have an high surgical probability within next months after revascularization. (4) We firmly believe that such patients could take a great advantage from this stenting strategy!

  References

  1. Luckie M, et al. Non-cardiac surgery and antiplatelet therapy following coronary artery stenting. Heart 2009; 95: 1303-1308 2. Poldermans D, et al., Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). Eur Heart J. 2009 Aug 27. [Epub ahead of print] 3. Piscione F, et al. A new approach to percutaneous coronary revascularization in patients requiring undeferrable non-cardiac surgery. Int J Cardiol. 2009 Aug 21. [Epub ahead of print] 4. Vicenzi MN, et al. Coronary artery stenting and non-cardiac surgery – a prospective outcome study. Br J Anaesth 2006;96:686–93.

  No conflict of interests to disclose.

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  Conflict of Interest:
  None declared.

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• Published on: 23 November 2015

  RE: Non-Cardiac Surgery and Anti-Platelet Therapy Following Coronary Artery Stenting

  • Luca Carmignani, Chief of Urology Department
  • Other Contributors:
    • Stefano Picozzi

  We read with great interest the work by Luckie et al, We read with great interest the work by Luckie et al., recently published in this Journal.1 There is an emerging problem of patients who have recently undergone coronary artery stent placement who then require noncardiac surgical interventions. This occurs in approximately 5% of the cases within 12 months of the stent placement.2 Coronary artery stenting is followed by a p...

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  We read with great interest the work by Luckie et al, We read with great interest the work by Luckie et al., recently published in this Journal.1 There is an emerging problem of patients who have recently undergone coronary artery stent placement who then require noncardiac surgical interventions. This occurs in approximately 5% of the cases within 12 months of the stent placement.2 Coronary artery stenting is followed by a period of double anti-aggregant therapy which, in the case of drug-eluting-stents (DES), should last for at least 12 months.3 This double antiplatelet therapy with aspirin and clopidrogrel, and its management in the post-operative period, becomes a problem in a patient who is found to have a disorder necessitating surgery that cannot be postponed. We are having to manage this problem ever more frequently in our Division, located within a structure with highly specialized cardiology facilities. Since October 2007, 18 surgical procedures have been carried out on 13 patients who had undergone coronary artery stenting with DES in the preceding 12 months. The disorders requiring surgery were: bladder cancers, urothelial neoplasia of the upper urinary tract, kidney tumors and benign prostatic hypertrophy causing multiple admissions because of haematuria and anemia. All the neoplastic disorders were newly diagnosed. These patients represent 1.6% of all the patients in our catchment area treated with coronary artery stents at our hospital. We believe that it is important to note that these neoplastic lesions, identified in the majority of cases (9/12) within 6 months after the cardiac operation, could have been detected prior to the intervention through a full abdominal ultrasound examination. This would have aided rational management of the patient, also in light of the fact that three of the patients required emergency surgery because of life-threatening bleeding. It is, therefore, licit to wonder whether complete abdominal ultrasonography, not only for urological but also for vascular, surgical and gynecological pathologies, should be considered an essential part of the pre-operative work-up and decision-making process. This examination could be of fundamental importance for disorders that are unrecognized and asymptomatic at the time of the cardiac procedure, not least because international guidelines recommend the implantation of bare metal stents or angioplasty (which require anti-aggregant therapy for 4-6 weeks) in patients who are expected to undergo non-cardiac surgery within 12 months of placement of a stent. 1. Luckie MJ, Khattar RS, Fraser DG. Noncardiac Surgery and Antiplatelet Therapy Following Coronary Artery Stenting. Heart 2009; Feb 12 (Epub ahead of print). 2. Vicenzi MN, Meislitzer T, Halaj HM, Fleisher LA, Metzler H. Coronary artery stenting and non-cardiac surgery – a prospective outcome study. Br J Anaesth 2006; 96: 686-693. 3. Silber S, Albertsson P, Aviles FF et al. Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur Heart J 2005; 26: 804-847.

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  Conflict of Interest:
  None declared.

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