Surgery after drug-eluting stent implantation: it's not all doom and gloom!

Up to 15-23% of the patients with percutaneous coronary intervention (PCI) and drug-eluting stent (DES) implantation need a surgical procedure <12 months from PCI. Perioperative risk stratification in these patients is challenging and should take into account many individual clinical and anatomic variables, along with the intrinsic surgical risk for ischemic and bleeding events. The presence of DES has always been considered as a harbinger of doom. In fact, DES are associated with delayed vascular healing and require longer dual antiplatelet treatment. Perioperative pharmacologic management in those patients is intricate because of the tradeoff between the increased thrombotic risk associated with premature DAPT discontinuation and the increased risk of bleeding in the presence of antithrombotics. Whilst most of the studies agree upon the inverse relationship between time from stenting to surgery and cardiac risk, more recent data challenge the previous belief that surgery should be deferred at least 12 months after DES implantation and this safety window could be shortened to <6 months or even less with new-generation DES. The aim of this brief commentary is to critically review available data about cardiac risk associated with surgery in patients with coronary drug-eluting stents.