Updated October 2025

Perioperative Cardiology

Perioperative Management of Patients With Coronary Stents

Patients with prior coronary stents face competing risks of stent thrombosis and surgical bleeding. The safest strategy hinges on surgery timing relative to stent placement, individualized antiplatelet management, procedural bleeding risk, and multidisciplinary coordination. Continue aspirin whenever possible, delay elective noncardiac surgery until a safer window (≥30 days for BMS; ≥6 months for DES when feasible), and avoid premature interruption of P2Y12 therapy. If interruption is unavoidable, minimize the gap and consider bridging in exceptional, very-high-thrombotic-risk cases.

Clinical question

How should clinicians optimize perioperative timing, antiplatelet therapy, and complication prevention for patients with coronary stents undergoing noncardiac surgery?

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Key points

Prioritize timing relative to PCI

Elective surgery is safest after endothelialization: ≥30 days for BMS, and preferably ≥6 months for DES; risk declines substantially beyond 6 months after DES ^[3], ^[4].

Preserve antiplatelet protection

Maintain aspirin through surgery if bleeding risk permits; stop clopidogrel/ticagrelor ~5 days, prasugrel ~7 days preop only when essential, and restart early post-op ^[6].

Recognize catastrophic risk

Perioperative stent thrombosis frequently causes MI and death; early DES/BMS periods carry the highest risk, especially with DAPT interruption ^[1], ^[2].

Use a team-based plan

Engage cardiology, anesthesia, and surgery to balance bleeding vs thrombosis, define drug timing, and plan rescue strategies ^[7], ^[8], ^[5].

Stratify by surgical bleeding risk

Low/moderate bleeding procedures usually allow aspirin continuation; for high-bleeding-risk surgery, minimize interruption duration and resume promptly ^[6].

Evidence highlights

Within weeks after PCI; catastrophic MI common ^[1], ^[2]

Highest stent-thrombosis risk

Most patients do well when surgery is >6 months post-PCI ^[3], ^[4]

Safer window after DES

Continue aspirin; interrupt P2Y12 only if necessary, with planful timing ^[5], ^[6]

Core antiplatelet rule

Clinical Pathway

Stepwise Perioperative Approach for Patients With Coronary Stents

This sequence balances ischemic and bleeding risks and aligns with contemporary evidence emphasizing timing, antiplatelet stewardship, and multidisciplinary agreement.

1) Define PCI details and thrombotic risk

Identify stent type (BMS vs DES), PCI date, clinical indication (ACS vs stable CAD), lesion complexity, and prior stent complications. Early post-PCI periods carry the greatest thrombosis risk, particularly if DAPT is interrupted ^[1], ^[2].

2) Classify surgical bleeding risk

Categorize the planned procedure as low, intermediate, or high bleeding risk. Aspirin can typically be continued for most low/moderate-bleeding procedures, while high-risk procedures may necessitate P2Y12 interruption and rare aspirin cessation ^[6].

3) Optimize timing of surgery relative to stent placement

For elective cases, defer surgery when possible: BMS ≥30 days; DES ≥6 months (risk sharply lower beyond 6 months) ^[3], ^[4]. When urgent, proceed with maximal antiplatelet protection and enhanced monitoring ^[7], ^[8].

4) Plan perioperative antiplatelet management

Prefer to continue DAPT if within the high-risk early window. If interruption is required: stop clopidogrel/ticagrelor ~5 days and prasugrel ~7 days pre-op while continuing aspirin; restart the P2Y12 inhibitor as soon as hemostasis is secure ^[6].

5) Consider bridging only in exceptional scenarios

For very high thrombotic risk (e.g., early post-PCI, complex DES, recent ACS) facing prohibitive surgical bleeding with DAPT, consider short-acting IV antiplatelet bridging strategies on a case-by-case basis in specialized centers; evidence remains limited and practice heterogeneous ^[8], ^[5].

6) Intra- and postoperative vigilance

Use meticulous hemostasis, avoid hypotension and tachycardia, and maintain oxygenation. Monitor for ischemia (ECG changes, troponin in high-risk patients) and restart antiplatelet therapy promptly to mitigate stent thrombosis ^[7], ^[8].

Risk–Benefit Essentials

Key Considerations, Evidence Signals, and Practical Pearls

Use these quick-reference items to guide bedside decisions and team communication.

Timing Benchmarks

BMS: elective NCS ideally delayed ≥30 days post-implant when feasible ^[7], ^[1].

DES: elective NCS ideally delayed ≥6 months; outcomes generally favorable beyond this threshold ^[3], ^[4].

If surgery cannot wait, prioritize maintaining antiplatelet therapy and cardiology input ^[8].

Antiplatelet Rules of Thumb

Continue aspirin perioperatively when bleeding risk allows; it reduces thrombotic risk without large bleeding penalties in many surgeries ^[6].

Hold P2Y12 only if essential: clopidogrel/ticagrelor ~5 days, prasugrel ~7 days pre-op; restart early post-op ^[6].

Avoid stopping all antiplatelet agents in the early post-PCI period whenever possible ^[1], ^[2], ^[5].

High-Risk Flags for Thrombosis

Surgery within weeks to a few months after PCI, especially DES ^[1], ^[3].

Interruption of DAPT, particularly in the first months post-PCI ^[1], ^[2].

Complex lesions (bifurcation, long stents), prior stent thrombosis, ACS indication ^[8].

Complications and Outcomes

Perioperative stent thrombosis is catastrophic, often causing Q-wave MI and death ^[1], ^[2].

Observational data indicate improved outcomes when surgery is beyond 6 months after DES ^[3], ^[4].

Large administrative cohorts show elevated postoperative complications in prior-stent patients vs controls, necessitating risk modification and monitoring ^[9].

Team and Process

Early coordination among cardiology, anesthesia, and surgery to document an individualized plan ^[7], ^[8], ^[5].

Specify exact stop/restart dates and rescue strategies (e.g., postoperative heparin is not a substitute for antiplatelets) ^[5], ^[6].

Ensure access to emergent PCI if major ischemia occurs perioperatively ^[7], ^[8].

Evidence Certainty

Strong observational and consensus support for timing thresholds and aspirin continuation ^[1], ^[3], ^[4], ^[6].

Evidence for bridging is limited and heterogeneous; use selectively with specialist input ^[8], ^[5].

Risk–benefit must be individualized; randomized data are sparse in modern DES eras ^[8], ^[5].

References

Source material

Primary literature that informs this article.