Assessing coronary stenting complications

For a long time, physicians and researchers have understood coronary stenting may lead to complications and future surgeries. A recent study suggests the risk may be higher than previously thought.

A retrospective, registry analysis of Italian adults undergoing PCI and stenting found that 14.3 percent underwent surgery within a year of the procedure and 40.0 percent underwent surgery within five years. The results were published online in Circulation: Cardiovascular Quality and Outcomes on Dec. 8.

Within 30 days of surgery, 4.4 percent of patients died, 2.5 percent had a cardiac death occurred, 1.5 percent had nonfatal MI and 6.4 percent had a serious bleeding event.

Of the patients, 9.1 percent had noncardiac surgeries within a year of PCI, which is much higher than the 5 percent estimate that previous research found, according to the study authors.

Nearly 80 percent of the surgeries were noncardiac in nature, while 35 percent were performed within a year from PCI.

“In these patients, the tradeoff between reduction of ischemic risk with antithrombotics and increased bleeding risk is difficult, and in many instances, therapeutic decisions are arbitrary and not evidence-based,” the researchers wrote.

The researchers mentioned that new generation drug-eluting stents appeared to be the safest stent option for surgeries performed within six months of PCI and were comparable to bare metal stents for surgeries performed more than a year after PCI. Still, they warned that not many patients received new generation drug-eluting stents, so more research needs to be done.

Guidelines suggest that patients receive dual antiplatelet therapy for at least one month after bare metal stent implantation and for six to 12 months after drug-eluting stent implantation. The researchers mentioned that discontinuing antiplatelet therapy increases the risk of stent thrombosis and cardiac ischemic events, while continuing antiplatelet therapy increases the bleeding risk.

They also noted that guidelines recommend that elective surgery be delayed until 30 to 45 days after bare metal stent implantation and one year after drug-eluting stent implantation. Elective noncardiac surgery is generally discouraged, although they mentioned it may be considered beyond six months following drug-eluting stent implantation.

The results suggest the need for pharmacological treatment strategies to decrease the ischemic and bleeding risk in patients with coronary stents undergoing surgery, according to the researchers. Options include tirofiban or cangrelor (Kengreal, The Medicines Company), which the FDA approved in June 2015. Still, more research is needed to determine the best option.

Tim Casey
-Executive Editor