Subsequent surgery common following coronary stenting

Nearly 15 percent of patients who received coronary stents during a PCI underwent another surgery within a year of the procedure and 40 percent had surgery within five years, according to a population-based, multicenter study. Nearly 80 percent of the surgeries were noncardiac in nature.

The researchers also found that approximately 18 percent of the surgeries had a high cardiac risk and 25 percent had a high bleeding risk. They added that surgery led to a 1.58 times increase in the risk of cardiac death.

Lead author Francesco Saia, MD, PhD, of the University of Bologna in Italy, and colleagues published their results online in Circulation: Cardiovascular Quality and Outcomes on Dec. 8.

They examined patients who were enrolled in an Italian registry and underwent PCI and stenting between July 2002 and December 2011. The median follow-up period was 4.8 years.

For patients undergoing surgery, the researchers assessed the incidence of cardiovascular death, MI and serious bleeding events at 30 days. They defined cardiac death as “the combination of death from a clearly identifiable cardiovascular cause or sudden/unexplained death,” while they defined a serious bleeding event as “hemorrhagic stroke and any bleeding requiring intervention or unplanned red blood cell transfusion or leading to death or a new hospitalization.”

The cumulative incidence of any surgery was 3.6 percent at 30 days, 9.4 percent at six months, 14.3 percent at one year and 40 percent at five years. Meanwhile, the cumulative incidence of any noncardiac surgery was 1.3 percent at 30 days, 5.1 percent at six months and 9.1 percent at one year, while the cumulative incidence of any cardiac surgery was 0.8 percent, 2.1 percent and 2.6 percent, respectively.

Of the surgeries performed, 79.8 percent were noncardiac and 29 percent were done on an urgent basis. The rates of urgent procedures were 2.7 percent at 30 days, 4.5 percent at six months and 5.7 percent at one year, while the rates of nonurgent procedures were 0.9 percent, 5 percent and 8.7 percent, respectively.

Within 30 days of surgery, death occurred in 4.4 percent of patients, cardiac death occurred in 2.5 percent of patients, nonfatal MI occurred in 1.5 percent of patients and a serious bleeding event occurred in 6.4 percent of patients. In addition, 10.5 percent of the serious bleeding events were fatal.

The researchers mentioned that new generation drug-eluting stents appeared to be safer than older drug-eluting stents and bare metal stents when surgery was performed within six months of PCI. New generation drug-eluting stents also were safer than older drug-eluting stents and comparable to bare metal stents when surgery was performed more than a year after PCI.

However, the researchers noted that the use of drug-eluting stents was low, so they said the findings about new generation drug-eluting stents “can only be viewed as hypothesis generating.”

They also mentioned that the retrospective design of the study was a limitation and that they did not have information on pharmacological treatments patients took at the time of surgery and when they had adverse events. In addition, they did not include outpatient surgeries and invasive diagnostic procedures in this analysis.