Drug-eluting stent thrombosis in patients undergoing non-cardiac surgery
New Delhi, India
* E-mail: tempedeepak{at}hotmail.com
Editor—I read with great interest the recent article by Godet and colleagues1 on drug-eluting stent (DES) thrombosis. Recent literature indicates that barring neurosurgery, the risk of bleeding is small if the antiplatelet medication is continued, but the risk of acute coronary event due to stent thrombosis is high if the medication is discontinued. The risk of a cardiac event is greater in patients with recent stents.2 3 The results of Godet's study suggest that the risk of specific thrombotic complications of DES is uncommon, despite discontinuing the antiplatelet medicines. However, analysis of the results reveals that the delay between DES and surgery was 14 months. The details of this delay are not provided, specifically in patients in whom the antiplatelet medicines were discontinued and those who suffered complications. The latest American College of Cardiology (ACC)/American Heart Association (AHA) guidelines recommend that all elective surgery should be postponed until 1 yr after DES implantation.4 Recent data also indicate that clopidogrel should be continued for 1 yr after all types of DES, despite the increased risk of bleeding.5 This indirectly implies that clopidogrel may be discontinued for non-cardiac surgery after 1 yr of placement. Thus, if the interval between the DES implantation and the non-cardiac surgery is 
12 months, Godet and colleagues are actually following the ACC/AHA guidelines and discontinuation of clopidogrel is permissible. In this scenario, the results would confirm the correctness of the guidelines. Therefore, the details of the interval between DES implantation and the non-cardiac surgery in this study become important and should be provided. Further, the results also confirm that the risk of bleeding is indeed low, because only three patients undergoing carotid endarterectomy developed moderate haematoma.
Rennes, France
* E-mail: gilles.godet{at}chu-rennes.fr
Editor—We would like to thank Dr Tempe for his interest in our paper.1 In our article, the mean delay between DES insertion and date for non-cardiac surgery is 14 months (see Table 1 in Godet and colleagues)1. However, both SD (11 months) and range (1 week–36 months) show that the ideal 1 yr duration for clopidogrel treatment was not always attained in our series of patients. In fact, clopidogrel was discontinued mainly because of the need for surgery which was unplanned at the time of coronary revascularization. In contrast to the more dogmatic AHA-ACC guidelines, a short discontinuation of clopidogrel was decided on by the anaesthetists and surgeons of our team, with the advice of a cardiologist, in relation to the relative risks for (i) in-stent thrombosis (IST) and (ii) increased bleeding. As a result, we did not observe an increased risk of bleeding in our patients (bleeding is a well-known factor for postoperative cardiac complication in such patients). Concerning our attitude for management of antiplatelet agents, the low incidence of IST in this series does not allow us to demonstrate a strong relation between IST, on the one hand, and both delay between DES insertion and surgery, or discontinuation of antiplatelet agents, on the other.
References
1 Godet G, Le Manach Y, Lesache F, Perbet S, Coriat P. Drug-eluting stent thrombosis in patients undergoing non-cardiac surgery: is it always a problem? Br J Anaesth (2008) 100:472–7.
2 Vicenzi MN, Meislitzer T, Heitzinger B, Halaj M, Fleisher LA, Metzler H. Coronary artery stenting and non-cardiac surgery—a prospective outcome study. Br J Anaesth (2006) 96:686–93.
3 Chassot PG, Delabays A, Spahn DR. Perioperative antiplatelet therapy: the case for continuing therapy in patients at risk of myocardial infarction. Br J Anaesth (2007) 99:316–28.
4 Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation (2007) 116:1971–96.
5 Hodgson JM, Stone GW, Lincoff AM, et al. Late stent thrombosis: considerations and practical advice for the use of drug-eluting stents: a report from Society for Cardiovascular Angiography and Interventions Drug-eluting Stent Task Force. Catheter Cardiovasc Interv (2007) 69:327–33.[CrossRef][Web of Science][Medline]
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