Surgery and Stents

March 1, 2009

Stents are the ingenious hi-tech devices implanted in blocked coronary arteries by cardiologists, our high priests of interventional medicine. In the last 3-5 years we’ve learned unfortunately that coronary stents are not the panacea once hoped for. A major problem with stents is that they tend to become blocked off themselves unless anti-platelet medication, such as Plavix, is taken, for months or even years.

One of the main purposes of pre-surgery evaluation is to find out whether a patient has coronary artery disease and is therefore at risk for having a heart attack or other heart complication during or after surgery. We used to assume that  offering these patients stents (‘re-vascularisation’) would protect them from these kinds of heart problems.

In fact, studies have shown that patients who’ve been very recently ‘stented’ often have worse outcomes. For major surgery, anti-platelet drugs are usually stopped, in order to prevent bleeding. Unfortunately stopping these medications, combined with the complex effects of surgery on blood clotting, leads to a much greater chance that the stent, and therefore the artery, will block off, thereby causing the cardiac complication we were trying at all costs to avoid.

Guidelines from the American College of Cardiology, the American Heart Association, and the American Society of Anesthesiologists, now recommend postponing major elective surgery in which there is significant risk of bleeding, in patients with new coronary stents.

If you have a bare-metal stent the minimum recommended wait is 4-6 weeks. If you have a drug-eluting stent the wait is 12 months after implantation.

Decision-making (e.g. when to have the surgery, when to stop or continue medications) can be quite complex in this situation. Very often, surgery cannot be postponed, and the risks have to be carefully weighed to make a good choice.

What You Should Do

Make sure your anesthesiologist and your surgeon know that you have a coronary stent, when it was put in, what type it is, and what medications you are taking.

Assessing risks and benefits, to guide decision-making about going forward (or postponing) surgery, and about stopping or continuing anti-platelet drugs will involve a discussion between your surgeon, your anesthesiologist, and your cardiologist. With your input of course.

Reference

Practice Alert for the Perioperative Management of Patients with Coronary Artery Stents: A Report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology: January 2009 – Volume 110 – Issue 1 – pp 22-23. Link.


Surgery – A Good Time to Quit Smoking

January 17, 2008

Quitting smoking is just about the best thing anyone can do for their health.

Are there any benefits to smoking, now that it no longer has much sex appeal, and the French have even banned it in the cafes of the Champs Elysees? The only medical benefit of smoking I know of is a reduction in the risk of postoperative nausea and vomiting (PONV). The cause is not certain, but numerous studies have shown this to be true. Although PONV isn’t much fun this is not, I hasten to add, a good reason to take up the noxious weed before your next operation.

No SmokingSmoking creates added risk for people having surgery and anesthesia. For instance, smoking increases your risk of respiratory complications, and your risk of wound infection.

The perioperative period (before and immediately after surgery) creates forced abstinence – try lighting up in the surgical ward these days and you will pretty soon find yourself surrounded by irate nurses, fellow patients and possibly the security staff. So surgery represents a perfect opportunity to quit.

A new meta-analysis (study of studies) in the Canadian Journal of Anesthesia confirms that the preoperative setting represents a “teachable moment”. Read the rest of this entry »