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Eur J Cardiothorac Surg 2007;31:1149-1150. doi:10.1016/j.ejcts.2007.03.007
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Letters to the Editor |
Department of Cardiothoracic Surgery, Wythenshawe Hospital, Manchester M23 9LT, UK
Received 27 January 2007; accepted 6 March 2007.
* Corresponding author. Tel.: +44 161 9987070; fax: +44 161 2912530. (Email: surjun{at}doctors.org.uk).
Key Words: Coronary stent • Lung cancer • Thrombosis • Mediastinoscopy
In the current era of percutaneous coronary intervention (PCI), we were interested to read the article by Brichon et al. [1], reporting coronary stent thromboses following lung resection, despite 4 weeks of dual antiplatelet therapy as according to American College of Cardiology/American Heart Association (ACC/AHA) guidelines [2]. It highlights what is set to be an increasing occurrence in thoracic surgical practice. While bare metal intravascular stents have been used for the better part of 20 years, their successor cytotoxic drug eluting stents (DES) are now deployed as the panacea for coronary artery disease. We have experienced a fatal outcome for a 43-year-old male type II diabetic, ex-smoker undergoing cervical mediastinoscopy for investigation of mediastinal lymphadenopathy, due to thrombosis of a DES to the left anterior descending (LAD) artery, deployed 6 months earlier. Primarily as thromboembolic prophylaxis, preoperatively, the patient had received 8-h 5000 IU subcutaneous calcium heparin. However, as control of bleeding in minimal access procedures such as this depends greatly on intact hemostatic physiology, aspirin and clopidogrel had been discontinued 7 days prior to surgery in accordance with our thoracic preoperative protocol. Acute LAD stent occlusion was confirmed on emergency coronary angiography. Rescue percutaneous coronary intervention by our cardiologists was unsuccessful and the patient had a rapid demise.
Elective non-cardiac surgery has been recommended to be delayed until 6 weeks after coronary bare metal stenting [3]. The diagnostic work-up and treatment of cancer, however, cannot afford this time luxury. There is, in fact, no recommendation made by the ACC/AHA 2005 guidelines with regard to antiplatelet therapy in coronary stent patients undergoing subsequent non-cardiac surgery. Furthermore, a recent meta-analysis [4] of 14 randomized clinical trials involving over 6000 coronary stent patients found significant thrombotic rates in DES beyond 1 year compared to bare metal stents, bringing into question the ACC/AHA guidelines of dual antiplatelet therapy for 6 months for paclitaxel stents and 3 months for sirolimus stents [2]. The mechanism is thought to be the suppression of re-epithelialization and thus a long-standing, and perhaps permanent, prothrombotic nidus. With the proliferation of coronary DES implantation, this perioperative management dilemma will be increasingly common, particularly in thoracic surgical patients, who often share with coronary artery disease a common risk factor in smoking. Ultrasound-guided non-stent PCI and single antiplatelet agent should be a considered alternative [5]. Were it not for positron emission tomography taking over much of the staging diagnostics for lung cancer, there may well be even more catastrophic incidents in thoracic surgical patients who have had coronary stenting.
Footnotes
\#9734; The authors of the original paper [1] were invited to comment on this Letter to the Editor but felt a reply was not necessary.
References
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