Perioperative Management After Coronary Stenting: Risk Assessment Before Surgery. Christian Seiler No conflict of interest to declare.

Transcription

1 Perioperative Management After Coronary Stenting: Risk Assessment Before Surgery Christian Seiler No conflict of interest to declare

2 PCI Long-Term Outcome Perioperative Management After Coronary Stenting: Risk Assessment Before Surgery

3 Risks of Non-Cardiac Surgery (Sx) Required within 1 yr in 5% of pts undergoing stenting -Early stop of antiplatelet tx due to bleeding risk -Hypotension, coronary perfusion - Platelet activation, fibrinogen level - Inflammatory state MACE rate 45% for Sx within 1yr MACE rate doubled for Sx within 35 days Korte et al. Thromb Haemost 2011; 105: 743-

4 Preventing the MACE Stent Thrombosis (vs Bleeding) by Antiplatelet Therapy

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6 Seiler. Collateral Circulation of the Heart. Springer, London, 2009

7 Cumulative survival (%) Peri-PCI Angiographic Collaterals and Survival in AMI Collaterals present (n=264) p=0.012 Collaterals absent (n=900) 6-months survival after stent thrombosis BMS: 79-89% DES: 55-71% Time of follow-up (days) Antoniucci et al. Am J Cardiol 2002; 89: 121-

8 Collateral Flow Index (CFI) Following PCI Perera et al. Circulation 2007; 115: 2015-

9 Collateral Flow Index 6 Months After Stent Implantation Meier P et al. J Am Coll Cardiol 2007; 49: 15-

10 Collateral conductance (ml/min/100mmhg) Time Course of Collateral Growth in the Rabbit Hindlimb Y Saline W MCP-1 W Y weeks occlusion + 1 week treatment (p=not significant) W W Y Acute arterial 1 week 4 weeks occlusion Hoefer et al. CVR 2001; 49: 609-

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14 L.K., , -Angina pectoris and dyspnea for 3-4 months -Diabetes, Htn, smoking -LVEF=60% -ASA, Insulin, Ca-antag, Pantoprazol, Citalopram -RCA CTO -PCI ostial and mid LCX (end 10:58) -Clopidogrel 600mg: 10:57 -Vasovagal reaction 30min after PCI -Cardiogenic shock -PCI stent thrombosis, LV assist device -Death (13:32)

15 Bioavailablity of Clopidogrel Peak plasma levels (3 mg/l) of the main circulating metabolite occurring approximately 1 hour after dosing

16 Pathophysiology of Stent Thrombosis Virchow s Triad 1. Phenomena of interrupted blood-flow 2. Phenomena associated with irritation of the vessel.. 3. Phenomena of blood-coagulation

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18 Risk Factors for Stent Thrombosis: L.K. Clinical Late start of dual platelet tx Advanced age Diabetes Stenting in ACS Renal insufficiency Low LVEF Impaired response to clopidogrel Interventional Ostial stent Long stents Stent-Ø 2.5mm Overlapping stents Suboptimal result May et al. Thromb Haemost 2008; 99: 487-

19 Collateral Damage to the Heart of L.K.

20 Antiplatelet Tx Following Coronary Stenting BMS: 1 month ASA + clopidogrel (dual tx) DES: 12 months dual tx ACS: 12 months dual tx regardless of stent Silber et al. Eur Heart J 2005; 26: 804-

21 Antiplatelet Tx for PCI Before Elective Non-cardiac Surgery Luckie et al. Heart 2009; 95: 1303-

22 Indications for Coronary Revascularization Before Non-cardiac Sx -Acute ST elevation myocardial infarction (MI) -Non-ST elevation MI -High-risk unstable angina pectoris -Stable angina pectoris with left main stenosis -Stable angina pectoris with 3-vessel CAD -Stable angina pectoris with 2-vessel CAD with proximal LAD stenosis Luckie et al. Heart 2009; 95: 1303-

23 Antiplatelet Tx for Pts Undergoing Unexpected Non-cardiac Sx Luckie et al. Heart 2009; 95: 1303-

24 Coronary Stenting: Risk Assessment Before Surgery Risk of perioperative stent thrombosis (ST) -Is PCI, is stenting indicated? -Influenced mainly by stop of dual antiplatelet Tx - Timing of elective non-cardiac surgery Mono antiplatelet Tx during Sx: -Non-cardiac Sx in 6 weeks: BMS -Non-cardiac Sx in 1 year: DES - ST: DM, renal insufficiency, age, LVEF, ACS - ST: Ostial, bifurcation lesions; long/small, overlapping stents, stent malapposition

25 Cumulative incidence of stent thrombosis Long-Term Outcomes with Zotarolimus-Eluting vs Bare-Metal Coronary Stents (Recommended dual antiplatelet tx = 3-6 months) BMS ZES p=0.21 Time after initial procedure (days) Mauri et al. J Am Coll Cardiol Intv 2010; 3:1240-

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27 Perioperative Management After Coronary Stenting: the Role of Risk Assessment and the Antiplatelet Conundrum

28 Previous Coronary Stent Implantation and Cardiac Events in Patients Undergoing Non-cardiac Surgery Cruden et al. Circ Cardiovasc Interv 2010; 3: 236-

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30 RCA LAD

31 Area at Risk for Infarction and the Collateral Circulation Seiler. Collateral Circulation of the Heart. Springer, London, 2009

32 Collateral Damage to the Heart of L.K. Spalteholz. Die Arterien der Herzwand. S. Hirzel, Leipzig, 1924

33 Pressure (mmhg) i.c. ECG 15s 100 P ao P occl Time 2min

34 Risk Factors for Stent Thrombosis Clinical Early stop of antiplatelet tx Stenting in ACS Renal insufficiency Diabetes Low LVEF Advanced age Interventional Suboptimal result Ostial / bifurcation stents Long stents Overlapping stents Stent-Ø <3mm May et al. Thromb Haemost 2008; 99: 487-