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Perioperative Problematik: Stentthrombose

The risk of stent thrombosis in the perioperative setting

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Summary

Percutaneous coronary interventions associated with a need for long-term dual anti-platelet therapy are steadily increasing. Accordingly, reports of severe perioperative complications in this high-risk group of patients are also increasing. Complications can be categorized into two groups: coronary ischemia or myocardial infarction due to acute stent thrombosis or increased blood loss. Risk of stent thrombosis is higher compared to the risk of bleeding. The article discusses the perioperative management based on an informative case report and recent evidence: Elective surgery has to be postponed until the end of dual anti-platelet therapy. Management of patients planned for semi-elective surgery should be individualized with interdisciplinary consensus. If clopidogrel is withdrawn, aspirin should be administered throughout the perioperative period. Careful surgical technique is required. If surgery is planned within 12 months, implantation of bare metal stents is recommended.

Zusammenfassung

Die stetig zunehmende Zahl an perkutanen Koronarinterventionen und die damit verbundene obligatorische und langdauernde duale Antiplättchentherapie ließen in den letzten Jahren mehrere Berichte über schwerwiegende Komplikationen erscheinen, wenn sich solche Patienten operativen Eingriffen unterzogen. Diese Komplikationen lassen sich in 2 Gruppen unterteilen: erneute Koronarischämie/Myokardinfarkt durch akuten Stentverschluss/Stentthrombose bzw. verstärkter Blutverlust. Das Risiko der Stentthrombose ist höher im Vergleich zur Blutung. Dieser Artikel beleuchtet die perioperative Problematik am Beispiel eines gut dokumentierten Fallberichtes und der aktuellen Evidenz. Folgende Empfehlungen werden davon abgeleitet: alle elektiven Eingriffe sollen erst durchgeführt werden, wenn die duale Antiplättchentherapie vollständig durchgeführt wurde. Bei dringlichen und planbaren Eingriffen soll interdisziplinär ein maßgeschneidertes Vorgehen gewählt werden. Wenn Clopidogrel abgesetzt wird, soll Aspirin weitergegeben werden. Penible chirurgische Blutstillung ist unumgänglich. Ist eine Operation innerhalb von 12 Monaten geplant, sollen unbeschichtete Stents implantiert werden.

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Abbreviations

PTCA:

perkutane transluminale Coronarangioplastie

PCI:

perkutane Coronarintervention

BMS:

bare metal stent (unbeschichteter Edelmetallstent)

DES:

drug eluting stent (rapamycin oder paclitaxel -freisetzender Stent)

TASS:

Aspirin

MACE:

schwerwiegendes cardiales Ereignis

HIT:

heparininduzierte Thrombopenie

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Authors and Affiliations

  1. Universitätsklinik für Anästhesiologie und Intensivmedizin, Medizinische Universität Graz, Graz, Austria

    Martin Norbert Vicenzi

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  1. Martin Norbert Vicenzi
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Correspondence to Martin Norbert Vicenzi.

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Vicenzi, M. Perioperative Problematik: Stentthrombose. Wien Med Wochenschr 159, 501–506 (2009). https://doi.org/10.1007/s10354-009-0715-3

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