Perioperative Management of the Patient with a Stent
Patients who present for surgery often have a variety of conditions that may or may not be directly related to their surgery. For example, patients undergoing noncardiac surgery can have heart conditions that do not change the surgery itself, but can increase risk of adverse events. Patients who use stents to maintain adequate blood flow to the heart present challenging cases to anesthesia providers. Because of the high prevalence of heart disease and stent use, anesthesiology practitioners should be familiar with the mechanisms and types of stents, the patients who need to use stents and perioperative considerations for those patients.
A stent is a wire mesh tube that is inserted into an artery to prop it open.1 The stent is inserted using a balloon catheter, which expands inside the artery to make room for the tube, and is meant to stay inside the body.1 Stents come in a variety of forms.2 The most basic stents are called bare metal stents, and they have no special coating and are held in place by scar tissue that grow around them.3 Meanwhile, drug-eluting stents (DESs) are coated with a medication that prevents the risk of re-narrowing of the artery.2 Because DES implantation leads to a longer healing time, patients who undergo such a procedure must use acetylsalicylic acid (aspirin) therapy for six to 12 months after to avoid thrombosis (blood clots).4 Recent types of stents include the bioresorbable scaffold, which releases a drug that reduces the likelihood of re-narrowing (restenosis) before the stent itself dissolves into the body;5 the antibody-coated stent, which attracts endothelial cells and promotes natural healing6 and the dual-therapy stent, which combines an anti-narrowing drug with antibody coating to prevent restenosis and promote healing.3,7 Some other types of stents, called stent grafts, are made out of fabric and are often used for larger arteries.8 Researchers continue to debate the value of different types of stents depending on patient needs and risks.9,10
A stent is necessary when a coronary artery (an artery feeding the heart muscle) becomes narrow due to a buildup of fatty deposits called plaques, which reduce blood flow.1 If blood flow to the heart muscle is reduced, a patient can have chest pain.1 If a clot completely blocks the blood flow to a part of the heart, the patient may have a heart attack.1 Stents work to combat coronary artery blockage and reduce the risk of heart attack.1 Coronary heart disease (CHD), or coronary artery disease, is the condition in which arteries are blocked and is the most common type of heart disease.11 In 2017, about 18.2 million American adults age 20 or older had CHD, and it was responsible for the deaths of 365,914 people in the United States.11 Patients with CHD commonly have other conditions such as hypertension, joint pain, hyperlipidemia, osteoarthritis, adiposity, thyroid disease, gout, diabetes mellitus, depression and cancer.12 Thus, a patient who needs or is using a stent may have complex heart issues and serious comorbidities.
Anesthesia providers who care for patients with stents must be cautious given the nature of stents and the patients’ other conditions. Preoperative evaluation of the type of stent, the time the stent was placed and the patient’s post-stent medication therapy is crucial to the patient’s success.13 Patients who undergo stent implantation must use antiplatelet therapy for an extended period of time, which can elevate their risk of intraoperative and postoperative bleeding.14 If the timing of surgery cannot be optimized, the anesthesia provider may need to consider preoperative discontinuation of the antiplatelet drugs in order to avoid excessive blood loss during a procedure.14 For example, Newsome et al. have developed a detailed preoperative protocol that entails collection of medical history, including type of stent, date of procedure and comorbidities; discontinuation of clopidogrel, a blood thinner typically used after DES placement; continuation of aspirin dosing throughout the perioperative period; preoperative therapy with eptifibatide and heparin; and postoperative re-administration of clopidogrel.15 Additionally, patients with intracoronary stents are at high risk for thrombosis.13 Therefore, the anesthesia provider must be alert throughout surgery for signs of a blood clot, which could cause a heart attack or stroke.13 If perioperative stent thrombosis does occur, immediate percutaneous coronary intervention (PCI; widening of the blocked artery) is indicated.16 The overall goal of the anesthesia provider should be to optimize preoperative medication discontinuation and surgical timing to avoid intra- or postoperative morbidity and mortality.17
Stents come in a variety of forms, and patients who use stents usually have serious heart conditions and other health issues. Anesthesia providers must be especially careful throughout a noncardiac surgery for a patient with a stent. A crucial part of caring for a patient with a stent is balancing preoperative discontinuation of antiplatelet drugs with prevention of intra- or postoperative cardiac events.18 Future research should investigate the safety of different anesthetic drugs and modalities in patients with CHD and stents.19
1.What Is a Stent? Dallas, TX: American Heart Association; 2017.
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3.OrbusNeich. Types of Coronary Stents. Patient Education 2020; https://www.orbusneich.com/en/patient/types-coronary-stents-0.
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19.Nath MP, Bhattacharyya D, Choudhury D, Chakrabarty A. Safety of spinal anaesthesia in patients with recent coronary stents. Southern African Journal of Anaesthesia and Analgesia. 2013;19(2):124–126.