Free-standing ambulatory surgery centers (ASCs) are facilities that perform same-day diagnostic and therapeutic procedures and are not attached to an acute care hospital.1 Free-standing ASCs are facilities that are physically separated from the hospital, and therefore, access to consultation, ancillary services (eg, laboratory, pharmacy, radiology, or blood bank), and percutaneous cardiac interventions may not be readily available. Increasing migration of surgical procedures from hospitals to ASCs has occurred because of lower costs achieved by ASCs compared to hospital-based outpatient departments2 and the perioperative care model at ASCs that make them more convenient and attractive to patients and surgeons.3 In addition, there are increasing pressures placed by stakeholders, including surgeons and proceduralists, who may jointly own ASCs, to expand the caseload so as to maintain economic viability of the facility. As a result, patients with significant comorbidities are frequently being scheduled for increasingly extensive surgical procedures (eg, knee and hip arthroplasty, spine surgery, thyroid/parathyroid surgery, and hysterectomy) in ASCs.4
Coronary artery disease (CAD) is highly prevalent among the surgical population of the United States and is a well-known risk factor for perioperative major adverse cardiovascular events (MACEs).5,6 In addition to medical therapy, treatment of CAD often includes minimally invasive percutaneous coronary interventions (PCIs), which usually consist of balloon angioplasty and coronary stent deployment.7–9 In fact, PCI is one of the most commonly performed therapeutic procedures in modern medicine.10 It is expected that patients with coronary stents will increasingly present for noncardiac surgery.11 It is estimated that up to 25% of patients who have coronary artery stent implantation will undergo noncardiac surgery within 2 years of their cardiac intervention.12
With increasing implantation of coronary artery stents over the past 2 decades,13,14 anesthesiologists practicing in outpatient settings will need to determine whether these patients are suitable for ambulatory procedures. Appropriate selection of patients with coronary artery stents requires consideration of factors that affect the balance between the risk of stent thrombosis due to interruption of antiplatelet therapy and the thrombogenic effects of surgery, as well as the risk of perioperative bleeding complications that may occur if antiplatelet therapy is continued.7,9,15–20 Given the potential comorbidity burden for this patient population and the complications associated with stent thrombosis and/or perioperative bleeding, periprocedure care of these patients can be challenging, particularly in free-standing ASCs. Therefore, the suitability of ASCs for this patient population remains highly controversial. In this Pro-Con commentary, we discuss the arguments for and against scheduling patients with coronary artery stents in free-standing ASCs.
PRO: ASC SETTING IS SUITABLE FOR A PATIENT WITH CORONARY STENTS
The presence of previous PCI, per se, may be indicative that the patient has a history of significant CAD and multiple cardiovascular risk factors (eg, hypertension, diabetes mellitus, and chronic renal disease), which can increase the risk of perioperative cardiac morbidity.5,7,9 However, in practice, only patients with optimized comorbid conditions (ie, American Society of Anesthesiologists [ASA] physical status of ≤III) are scheduled for procedures in an ASC,4 thus reducing the risk of perioperative MACE. Furthermore, the overall perioperative risk of MACE related to ambulatory surgery seems to be low, as reported by a study that found a 30-day incidence of myocardial infarction (MI) after outpatient surgery of about 0.1%.21 The combination of low overall perioperative risk of MACE related to ambulatory surgery and the well-optimized patient who presents for ambulatory surgery makes it possible to safely care for these patients in an ASC.
Patients with coronary stents are considered vulnerable to MACE related to stent thrombosis.22 Understanding the risk factors of stent thrombosis should allow appropriate patient selection and improve patient safety. The risk factors for stent thrombosis in the setting of elective surgery include the invasiveness of the scheduled surgical procedure, the indication for stent implantation, the type and number of stents implanted, the degree of revascularization achieved after PCI, the time elapsed since stent placement, and the need to hold antiplatelet therapy (Table 1).23
Table 1. -
Risk Factors for Coronary Stent Thrombosis (American College of Cardiology/American Heart Association Guidelines/French Guidelines)
|Invasive open surgical procedure
|Stent placed for acute coronary syndrome
|Type and number of stents
| First-generation drug-eluting stents
| Three or more stents implanted
| Long stents (>60 mm)
| Bifurcated stents or bifurcation with 2 stents implanted
|Previous stent thrombosis or inadequate antiplatelet therapy
| Diffuse multivessel disease
| Left ventricular ejection faction <30%
| Diabetes mellitus requiring insulin
| End-stage renal failure requiring dialysis
Adapted from the work of Fleisher et al5
and Godier et al.7
The invasiveness of the surgical procedure and associated proinflammatory response corresponds with the perioperative prothrombotic state.24 Although invasive procedures are increasingly performed in ASCs, most outpatient procedures are minimally invasive (eg, gastrointestinal endoscopic procedures, cataract surgery, cosmetic surgery, arthroscopy, etc.).25,26 Therefore, compared to inpatient surgery, the overall risk of adverse thrombotic events in this population is expected to be lower.27 The indication for PCI is another risk factor for MACE after surgery. It has been reported that the odds of postoperative MACE are about 5× higher within 3 months and 2× higher after 12 months of PCI when coronary stents are implanted to treat acute coronary syndrome (ACS).28 Of note, about two-thirds of PCI cases are performed on patients without ACS. Importantly, even the high-risk patients with a history of stent implantation for ACS are considered to have transitioned to stable ischemic heart disease after 1 year if they are symptom-free during this period.9
Reports of catastrophic postoperative outcomes after noncardiac surgery attributed to stent thrombosis were common in the early era of PCI.9,29 However, advances in revascularization techniques and the introduction of new generations of drug-eluting stents (DESs) have significantly reduced the risk of stent thrombosis and MACE after elective surgery. A study in the Veterans Affairs population (matched 20,590 surgical patients to 41,180 nonsurgical patients) conducted between 2000 and 2010 found that the incidence of postoperative acute MI and/or revascularization decreased from 9% when surgery was performed within the first 6 weeks of PCI to 2.3% when surgery occurred after 6 months from PCI.30 Of note, the risk of MACE 6 months after DES implantation in a subset of patients having outpatient procedures was similar to those who did not have surgery (1.5% vs 1.1%).30 Other studies have also found MACE rates of about 2% when elective surgery takes place >6 months after PCI.31,32
Due to concerns of stent thrombosis, dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor (eg, clopidogrel, prasugrel, ticagrelor, or cangrelor) is recommended for 6 months after newer DES implantation and 12 months after older DES implantation.9 Use of bare metal stents (BMSs) reduced the incidence of coronary thrombosis after PCI but was associated with increased risk of stent restenosis and repeat revascularization. According to current guidelines,9 elective surgery can be performed after 30 days from BMS implantation, and DAPT may discontinued for the procedure. After the high-risk period, patients continue to receive aspirin, which has not been shown to increase perioperative bleeding complications.9,31,33 In fact, perioperative aspirin is more likely to benefit rather than harm patients with previous PCI.34 Given the elective nature of procedures performed in ASCs, it is feasible to schedule the desired procedure at least 6 months after DES and 1 month after BMS, thus reducing the risk of MACE.
The decision to perform elective procedures in patients on DAPT depends on the perceived risk of bleeding complications. Risk factors for antiplatelet therapy-related bleeding complications include the type of surgical procedure (eg, closed-cavity procedures, such as intracranial surgery, intramedullary spine surgery, and transurethral prostate surgery), extensive open surgery, preoperative hemoglobin <12 g/dL, age, sex, functional status, kidney function, history of high-risk CAD, and active cancer.35 Many ambulatory surgical procedures have a low risk of bleeding and can be safely performed in ASCs in patients taking DAPT. Some national and international specialty societies have provided guidance in this respect. For example, the American Society for Gastrointestinal Endoscopy (ASGE),36 the Royal College of Ophthalmologists,37 and the American Society of Interventional Pain Physicians (ASIPP)38 provide a classification of common procedures based on their potential risk of bleeding in patients on antithrombotic therapy (Table 2). Recently, the European Society of Anaesthesiology and Intensive Care and the European Society of Regional Anaesthesia recommended that superficial nerve blocks and interfascial plane blocks may be performed in patients on antiplatelet therapy.39 DAPT could be continued for some urologic procedures, including ureteroscopy and cystoscopy.40 In patients undergoing ambulatory minor cosmetic surgery, it is accepted that monotherapy with aspirin is safe to continue, but evidence regarding continuation of clopidogrel is conflicting.41 Of note, if necessary, DAPT may be temporarily discontinued 5 to 7 days before surgery with minimal increase in stent thrombosis risk.9
Table 2. -
Procedure-Specific Risk of Bleeding in Patients on Antithrombotic Therapy
|Low risk for bleeding procedures (may continue dual-antiplatelet therapy)
||High risk for bleeding procedures
|American Society for Gastrointestinal Endoscopy
| Diagnostic esophago-gastro-duodenoscopy, colonoscopy, or flexible sigmoidoscopy
| Endoscopic retrograde cholangiopancreatography with stent placement or papillary balloon dilation without sphincterotomy
|| Biliary or pancreatic sphincterotomy
| Diagnostic balloon-assisted and capsule enteroscopy
|| Treatment of varices
| Endoscopic ultrasound without fine needle aspiration
|| Percutaneous endoscopic gastrostomy placement
| Argon plasma coagulation
|| Therapeutic balloon-assisted enteroscopy
|| Endoscopic ultrasound with fine needle aspiration
| Tumor ablation
| Ampullary resection
| Endoscopic submucosal dissection
| Pneumatic or bougie dilation
|Royal College of Ophthalmologists
| Cataract surgery under topical or subtenon anesthesia
|| Peri- or retro-bulbar anesthesia
| Corneal surgery
|| Glaucoma surgery
| Oculoplastic surgery: chalazion and eyelid cyst/lesion removal
|| Vitreo-retinal surgery
| Strabismus surgery
|| Endoresection or biopsy of intraocular tumors
| Oculoplastics: blepharoplasty and postseptal eyelid surgery
| Temporal artery biopsy
|American Society of Interventional Pain Physicians
| Trigger point and muscular injections
|| Cervical, thoracic, and interlaminar epidurals above L4-L5
| Peripheral joint injections
|| Cervical, thoracic, and lumbar above L3 transforaminal epidural injections
| Peripheral nerve blocks
|| Spinal cord stimulator trial and implant
| Sacroiliac joint and ligament injections and nerve blocks
|| Percutaneous adhesiolysis with interlaminar or transforaminal approach
| Caudal epidural injections
|| Percutaneous disk decompression (above L4/5)
| Ganglion impar blocks
|| Sympathetic blocks (stellate ganglion, thoracic splanchnic, and celiac plexus)
| Thoracic and cervical intradiscal procedures
| Vertebral augmentation, lumbar (above L4), thoracic, and cervical
| Intrathecal catheter and pump implant
Overall, the majority of patients with coronary stents scheduled for ambulatory surgery are suitable for free-standing ASCs. In addition to preoperative optimization of comorbid conditions, preoperative identification of risk factors for stent thrombosis (Table 1) and the need for continuation/discontinuation of DAPT should reduce the perioperative risk of stent thrombosis and bleeding complications. Most of the procedures performed in this setting are minimally invasive and, thus, have a low risk of stent thrombosis and perioperative bleeding. Given the elective nature of the procedures, they can be performed after the risk of stent thrombosis is significantly reduced (usually 6 months after DES placement and 1 month after BMS). The best timing for elective surgery is when patients are off of DAPT and are only on aspirin. Also, several procedures can be performed without discontinuation of DAPT (Table 2). Patient safety can be maintained with appropriate patient selection (Table 3).
Table 3. -
Pro and Con Factors in Scheduling Patients With Coronary Artery Stents at a Free-Standing Ambulatory Surgery Center
| Patient is scheduled for a noninvasive or minimally invasive diagnostic or therapeutic procedure
|| Patient is scheduled for invasive open surgical procedure
| Stent implanted to treat low-complexity coronary lesions (eg, coronary stents placed for treatment of short noncomplex lesions not including artery bifurcations or the left main coronary artery)
|| Reason for stent implantation was an acute coronary syndrome that occurred within 12 mo of ambulatory surgery
| Time elapsed since stent placement is >1 mo for bare-metal stents and 6 mo for newer drug-eluting stents
|| High-complexity coronary artery lesions
| Dual antiplatelet therapy has been discontinued and patient is only taking aspirin or the desired procedure can be performed without discontinuation of dual antiplatelet therapy
|| High risk of thrombosis ()
| High risk of perioperative bleeding if antiplatelet therapy is continued ()
| Dual antiplatelet therapy cannot be stopped before invasive surgery
| Patients with conditions requiring dual antiplatelet therapy plus antithrombotic therapy (eg, oral anticoagulants)
| Free-standing ambulatory center lacks immediate access to a facility with interventional cardiology services
Finally, to maintain patient safety, anesthesiologists practicing in such ASCs should be involved in timely preoperative evaluation and patient selection, as well as enhance their knowledge and skill sets to manage complex patients. Early identification of complications including stent thrombosis and bleeding is critical for patient safety. Implementation of check lists, simulation drills with MACE scenarios, and protocols for prompt transition of care from the ASC to a hospital should improve preparedness of the ASC to manage patients with coronary stents. In the event of a perioperative coronary event, the ASC should be prepared to implement a rescue plan, which includes verification of the diagnosis of MACE with 12-lead electrocardiogram; early and appropriate treatment of severe pain, hypertension, or hypotension; administration of high-flow oxygen, aspirin, and beta blockers, if appropriate; and prompt transfer to a facility with interventional cardiology capabilities.42
CON: ASC SETTING IS NOT SUITABLE FOR A PATIENT WITH CORONARY STENTS
Patients with coronary stents can have significant cardiac disease and, therefore, are at an elevated risk of perioperative cardiac complications both from potential stent thrombosis and from myocardial ischemia from potential disease in the nonstented segments.43 Free-standing ASCs are not always equipped to manage such complex patients due to the lack of resources and personnel. Also, such complex patients require preoperative evaluation and optimization that is at least currently not routine in free-standing ASCs, as the patients are seen on the day of surgery. This might delay procedures and reduce ASC efficiency.44 More important, it might lead to inappropriate patient selection, which can compromise patient safety.4
Patients with stents implanted for ACS remain at risk of coronary stent-related complications for a longer time compared to patients with stents implanted for stable ischemic heart disease.28,45 It is important to recognize that BMS is usually selected for patients with higher cardiac risk scores, those with high risk of bleeding, patients who cannot tolerate DAPT because of active bleeding or nonadherence to medical therapy, and patients needing urgent operations.9 Higher rates of cardiac events after surgery have been observed in patients with BMS compared to DES.30 Therefore, although DAPT can be discontinued after 30 days of BMS implantation, these patients may have increased risk of cardiac complications for the same reasons that led to the decision to implant a BMS instead of a DES.
Interruption of DAPT before surgery is an independent correlate for MACE. Premature discontinuation of DAPT is the strongest predictor of stent thrombosis and is associated with an unacceptable rate of acute MI and a fatality rate as high as 45%.46 Therefore, at a minimum, elective surgery, and thus ambulatory procedures, should be delayed if patients are on DAPT that needs to be discontinued. Although there are recommendations for an optimal duration of DAPT,9 these need to be modified based on interplay between indications for stent placement, stent characteristics (eg, location, length, type, and number), and patient characteristics (eg, comorbidities, age, and use of other anticoagulants). With introduction of newer types of coronary stents and broadening indications for stent placements, the optimal duration of DAPT and the best perioperative care have been evolving, leading to challenges in the decision-making to offer the ambulatory setting for patients with coronary stents. To complicate matters, a recent observational study found no evidence for protective effects of DAPT from perioperative MACE in patients who have undergone previous PCI, while the risk of harm from bleeding was increased.47 Of note, the study lacked long-term follow-up and standardized monitoring of MACE.47 Even after discontinuation of DAPT, aspirin should be continued indefinitely and can increase the risk of perioperative bleeding complications.
The characteristics of the stented coronary lesion and the PCI procedural complexity should also be considered when offering ambulatory surgery to patients with coronary stents. Lesions consisting of high-risk vulnerable plaques, long-stenosed coronary segments, lesions located in the bifurcation of a vessel, complex lesions of the left main coronary artery, or multivessel disease are associated with increased risk of ACS.48–51 Similarly, PCI with implantation of multiple stents, treatment of a bifurcation lesion with 2 stents, incomplete coronary revascularization, malposition of the stent struts, or fracture or discontinuity in the deployed stents may modify the flow characteristics and has been associated with increased incidence of adverse cardiac events.11,23,46,52–55 Extended DAPT is of potential benefit in this patient population.56,57 As all the details about the PCI intervention and anatomy of the coronary lesions may not be readily available to anesthesiologists in the rapid-paced ASC environment, patients with complex lesions may be inadvertently scheduled at ASCs, exposing them to unnecessary perioperative risk of MACE.
Patients at high risk of thrombosis may not be suitable candidates for ambulatory surgery, particularly for invasive surgical procedures. For example, patients with insulin-treated diabetes mellitus have a 3-fold increase in the risk of stent thrombosis compared to nondiabetic patients.58,59 Similarly, heart failure with a left ventricular ejection fraction <30% has been associated with a nearly 3× times increased risk of early stent thrombosis.23 Advanced malignant disease is considered an acquired thrombophilic state, and therefore, poses a high risk of perioperative stent thrombosis.60 Patients with a previous history of stent thrombosis are at particularly high risk of perioperative ACS. It is estimated that about 20% of this patient population experience stent reocclusion within 3 years of the first occlusion, with a cumulative risk of cardiac death of about 28%.61,62 Other clinical factors, including advanced age, current smoking status, chronic renal failure on dialysis, liver disease, anemia, thrombocytopenia, inherited coagulation disorders, and thrombocytosis states, have also been implicated as risk factors for perioperative acute and subacute stent thrombosis.11,16,63–65
Atrial fibrillation shares similar risk factors with ACS, and therefore, is often found (5% to 23%) in patients with coronary stents.66 According to recent guidelines,67 prevention of stroke and stent thrombosis in this patient population should be achieved with dual antithrombotic-antiplatelet therapy, which includes combination of vitamin K antagonists or a direct oral anticoagulant (apixaban, dabigatran, edoxaban, or rivaroxaban) and a P2Y12 inhibitor. This more intense therapy significantly increases the risks of perioperative bleeding complications. Although it has been suggested that interruption of oral anticoagulants with continuation of antiplatelet therapy is reasonable for patients with atrial fibrillation and recent stent implantation,31 no specific recommendations currently exist for the perioperative management of this patient population.
Another major determinant of suitability for ambulatory surgery is the invasiveness and complexity of the surgical procedure because it influences not only the risk of stent thrombosis but also the risk of perioperative bleeding complications.30 High-risk patients with coronary stents for whom DAPT may not be stopped are not good candidates for invasive/extensive outpatient surgical procedures.30
Finally, patients who develop an ACS in the ambulatory facility will need immediate angiography and revascularization, thus requiring immediate transfer to an acute care hospital. Mortality after ST elevation myocardial infarction (STEMI) increases in direct proportion with the time elapsed between the onset of symptoms and reperfusion of the culprit vessel.68–70 Studies have revealed that for every 30-minute delay in PCI, the absolute risk of in-hospital mortality increases by 1%, and the risk of 1-year mortality increases by 7.5%.71 There is consensus among international scientific societies that the time between arrival to the hospital and balloon angioplasty (door-to-balloon time) should be no longer than 90 minutes.9,72–74 However, delays in treatment may occur related to the time needed to transfer the patient from the ASC to a PCI-capable hospital.
Overall, safe care of these patients requires consideration of the abovementioned variables. The patients with coronary stents are complex, and the duration of DAPT to mitigate the potential of stent thrombosis is variable and controversial. There may be delay in procedures as well as in discharging home, leading to reduced efficiency. Therefore, these patients may not be suitable for a free-standing ASC (Table 3).
In this era of value-based purchasing, the trend of performing complex procedures on challenging patients in free-standing ASCs will continue. It is no longer acceptable to demand that only healthy patients (ASA physical status I and II) are scheduled in free-standing ASCs. Considering the existing pressure to move more complex cases to ASCs, the decision to schedule patients with coronary stents in ASCs should be well informed.
Ambulatory procedures can be safely performed in ASCs for patients with coronary stents undergoing minimally invasive procedures, with lower comorbidity burden, low-complexity coronary lesions, longer time since stent implantation, and when DAPT has been discontinued or DAPT can be continued (Figure). On the other hand, procedures requiring temporary cessation of antiplatelet therapy for patients with high-risk lesions and complex PCIs or those with BMS warrant caution.
Appropriate screening and management before the day of surgery are needed. Preoperative assessment of patients with coronary stents should be aimed to determine whether the patient’s comorbidities are optimized, to estimate the perioperative risk of MACE due to stent thrombosis and coronary disease in the nonstented segments, and to evaluate the risk of perioperative bleeding or hematoma when antiplatelet therapy cannot be discontinued before surgery. Careful analysis of these 3 factors is of critical importance. If deemed necessary, patients should be referred for timely preoperative cardiology evaluation to determine the stability of patients’ CAD and provide instructions about appropriate management of antiplatelet therapy. Of note, ambulatory surgery requiring temporary cessation of DAPT for patients with high-risk lesions and complex PCI warrant discussion between the cardiologist, surgeon, anesthesiologist, and the patient. Involving the patient in decision-making (shared decision-making) requires transparency and education regarding the benefit and risk tradeoffs of performing the procedure at a free-standing ASC.3 Patients should be instructed regarding medications that need to be held or taken before surgery as well as the timing of restarting medications after surgery.
Finally, characteristics of ASCs prepared to take care of complex patients undergoing complex procedures include accreditation status, adequate qualified staffing, clinicians with local hospital admitting privileges, availability of technology and equipment, established emergency response protocols, transfer agreement with the local hospital and proximity of the ASC to a PCI-capable hospital, or, the best scenario, an angiography suite with ambulatory PCI capability.75
The authors thank Mark Kozak, MD, professor of medicine and radiology, Division of Cardiology, Penn State Heart and Vascular Institute, Hershey, PA, and Soraya Samii, MD, PhD, associate professor of medicine, Division of Cardiology, Penn State Heart and Vascular Institute, Hershey, PA.
Name: Eric B. Rosero, MD, MSc.
Contribution: This author was involved in writing and revising the manuscript, and final approval.
Conflicts of Interest: None.
Name: Niraja Rajan, MD.
Contribution: This author was involved in writing and revising the manuscript, and final approval.
Conflicts of Interest: None.
Name: Girish P. Joshi, MBBS, MD, FFARCSI.
Contribution: This author was involved in writing and revising the manuscript, and final approval.
Conflicts of Interest: G. P. Joshi has received honoraria from Baxter Pharmaceuticals.
This manuscript was handled by: Richard C. Prielipp, MD.
1. Vetter TR, Joshi GP. Ambulatory extended recovery: coming to an operating theater near you. Anesth Analg. 2020;131:695–698.
2. Friedlander DF, Krimphove MJ, Cole AP, et al. Where is the value in ambulatory versus inpatient surgery? Ann Surg. 2021;273:909–916.
3. Joshi GP. Putting patients first: ambulatory surgery facilitates patient-centered care. Curr Opin Anaesthesiol. 2021;34:667–671.
4. Rajan N, Rosero EB, Joshi GP. Patient selection for adult ambulatory surgery: a narrative review. Anesth Analg. 2021;133:1415–1430.
5. Fleisher LA, Fleischmann KE, Auerbach AD, et al.; American College of Cardiology; American Heart Association. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;64:e77–137.
6. Roberts JD, Sweitzer B. Perioperative evaluation and management of cardiac disease in the ambulatory surgery setting. Anesthesiol Clin. 2014;32:309–320.
7. Godier A, Fontana P, Motte S, et al.; members of the French Working Group on perioperative haemostasis (GIHP). Management of antiplatelet therapy in patients undergoing elective invasive procedures. Proposals from the French Working Group on perioperative haemostasis (GIHP) and the French Study Group on thrombosis and haemostasis (GFHT). In collaboration with the French Society for Anaesthesia and Intensive Care Medicine (SFAR). Anaesth Crit Care Pain Med. 2018;37:379–389.
8. Herbert T, Rizzolo D. The role of percutaneous coronary intervention in managing patients with stable ischemic heart disease. JAAPA. 2020;33:18–22.
9. Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention, 2011 ACCF/AHA guideline for coronary artery bypass graft surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease, 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction, 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes, and 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery. Circulation. 2016;134:e123–e155.
10. McDermott KW, Freeman WJ, Elixhauser A. Overview of operating room procedures during inpatient stays in U.S. Hospitals, 2014: Statistical Brief #233. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD); 2006.
11. Berger PB, Kleiman NS, Pencina MJ, et al.; EVENT Investigators. Frequency of major noncardiac surgery and subsequent adverse events in the year after drug-eluting stent placement results from the EVENT (Evaluation of Drug-Eluting Stents and Ischemic Events) Registry. JACC Cardiovasc Interv. 2010;3:920–927.
12. Hawn MT, Graham LA, Richman JR, et al. The incidence and timing of noncardiac surgery after cardiac stent implantation. J Am Coll Surg. 2012;214:658–66.
13. Elbadawi A, Elgendy IY, Ha LD, et al. National trends and outcomes of percutaneous coronary intervention in patients ≥70 years of age with acute coronary syndrome (from the National Inpatient Sample Database). Am J Cardiol. 2019;123:25–32.
14. Iverson A, Stanberry LI, Tajti P, et al. Prevalence, trends, and outcomes of higher-risk percutaneous coronary interventions among patients without acute coronary syndromes. Cardiovasc Revasc Med. 2019;20:289–292.
15. Chee YL, Crawford JC, Watson HG, et al. Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures. British Committee for Standards in Haematology. Br J Haematol. 2008;140:496–504.
16. Egholm G, Kristensen SD, Thim T, et al. Risk associated with surgery within 12 months after coronary drug-eluting stent implantation. J Am Coll Cardiol. 2016;68:2622–2632.
17. Mahmoud KD, Sanon S, Habermann EB, et al. Perioperative cardiovascular risk of prior coronary stent implantation among patients undergoing noncardiac surgery. J Am Coll Cardiol. 2016;67:1038–1049.
18. Rodriguez A, Guilera N, Mases A, Sierra P, Oliva JC, Colilles C; REGISTRESTENTS group. Management of antiplatelet therapy in patients with coronary stents undergoing noncardiac surgery: association with adverse events. Br J Anaesth. 2018;120:67–76.
19. Siller-Matula JM, Petre A, Delle-Karth G, et al. Impact of preoperative use of P2Y12 receptor inhibitors on clinical outcomes in cardiac and non-cardiac surgery: a systematic review and meta-analysis. Eur Heart J Acute Cardiovasc Care. 2017;6:753–770.
20. Gerstein NS, Albrechtsen CL, Mercado N, et al. A comprehensive update on aspirin management during noncardiac surgery. Anesth Analg. 2020;131:1111–1123.
21. Harrison TG, Hemmelgarn BR, James MT, et al. Association of kidney function with major postoperative events after non-cardiac ambulatory surgeries: a population-based cohort study. Ann Surg. Published online July 7, 2021. doi: 10.1097/SLA.0000000000005040.
22. Biccard BM, Rodseth RN. The pathophysiology of peri-operative myocardial infarction. Anaesthesia. 2010;65:733–741.
23. Ullrich H, Münzel T, Gori T. Coronary stent thrombosis—predictors and prevention. Dtsch Arztebl Int. 2020;117:320–326.
24. Smith BB, Warner MA, Warner NS, et al. Cardiac risk of noncardiac surgery after percutaneous coronary intervention with second-generation drug-eluting stents. Anesth Analg. 2019;128:621–628.
25. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory surgery in the United States, 2006. Natl Health Stat Report. 2009;11:1–25.
26. Steiner CA, Karaca Z, Moore BJ, et al. Surgeries in Hospital-Based Ambulatory Surgery and Hospital Inpatient Settings, 2014: Statistical Brief #223. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD); 2006.
27. Sweitzer B, Rajan N, Schell D, et al. Preoperative care for cataract surgery: the Society for Ambulatory Anesthesia Position Statement. Anesth Analg. 2021;133:1431–1436.
28. Holcomb CN, Hollis RH, Graham LA, et al. Association of coronary stent indication with postoperative outcomes following noncardiac surgery. JAMA Surg. 2016;151:462–469.
29. Kałuza GL, Joseph J, Lee JR, Raizner ME, Raizner AE. Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol. 2000;35:1288–1294.
30. Holcomb CN, Graham LA, Richman JS, et al. The incremental risk of noncardiac surgery on adverse cardiac events following coronary stenting. J Am Coll Cardiol. 2014;64:2730–2739.
31. Cao D, Chandiramani R, Capodanno D, et al. Non-cardiac surgery in patients with coronary artery disease: risk evaluation and periprocedural management. Nat Rev Cardiol. 2021;18:37–57.
32. Byrne RA, Joner M, Kastrati A. Stent thrombosis and restenosis: what have we learned and where are we going? The Andreas Grüntzig Lecture ESC 2014. Eur Heart J. 2015;36:3320–3331.
33. Fellahi JL, Godier A, Benchetrit D, et al. Perioperative management of patients with coronary artery disease undergoing non-cardiac surgery: summary from the French Society of Anaesthesia and Intensive Care Medicine 2017 convention. Anaesth Crit Care Pain Med. 2018;37:367–374.
34. Graham MM, Sessler DI, Parlow JL, et al. Aspirin in patients with previous percutaneous coronary intervention undergoing noncardiac surgery. Ann Intern Med. 2018;168:237–244.
35. Roshanov PS, Guyatt GH, Tandon V, et al. Preoperative prediction of Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS): an international prospective cohort study. Br J Anaesth. 2021;126:172–180.
36. Acosta RD, Abraham NS, DeWitt JM. Response. Gastrointest Endosc. 2016;83:1305–1306.
37. Makuloluwa AK, Tiew S, Briggs M. Peri-operative management of ophthalmic patients on anti-thrombotic agents: a literature review. Eye (Lond). 2019;33:1044–1059.
38. Kaye AD, Manchikanti L, Novitch MB, et al. Responsible, safe, and effective use of antithrombotics and anticoagulants in patients undergoing interventional techniques: American Society of Interventional Pain Physicians (ASIPP) guidelines. Pain Physician. 2019;22:S75–S128.
39. Kietaibl S, Ferrandis R, Godier A, et al. Regional anaesthesia in patients on antithrombotic drugs: joint ESAIC/ESRA guidelines. Eur J Anaesthesiol. 2022;39:100–132.
40. Culkin DJ, Exaire EJ, Green D, et al. Anticoagulation and antiplatelet therapy in urologic practice: ICUD and AUA Review Paper. J Urol. 2014;192:1026–1034. Accessed May 16, 2022. https://www.auanet.org/guidelines/anticoagulation-and-antiplatelet-therapy
41. Isted A, Cooper L, Colville RJ. Bleeding on the cutting edge: a systematic review of anticoagulant and antiplatelet continuation in minor cutaneous surgery. J Plast Reconstr Aesthet Surg. 2018;71:455–467.
42. Bansal VK, Dobie KH, Brock EJ. Emergency response in the ambulatory surgery center. Anesthesiol Clin. 2019;37:239–250.
43. Hollis RH, Holcomb CN, Valle JA, et al. Coronary angiography and failure to rescue after postoperative myocardial infarction in patients with coronary stents undergoing noncardiac surgery. Am J Surg. 2016;212:814–822.e1.
44. Joshi GP, Vetter TR. Causes of delays in the ambulatory surgery center setting: a keen grasp of the obvious? Anesth Analg. 2021;133:1402–1405.
45. Kereiakes DJ, Yeh RW, Massaro JM, et al.; DAPT Study Investigators. DAPT score utility for risk prediction in patients with or without previous myocardial infarction. J Am Coll Cardiol. 2016;67:2492–2502.
46. Iakovou I, Schmidt T, Bonizzoni E, et al. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA. 2005;293:2126–2130.
47. Howell SJ, Hoeks SE, West RM, et al.; OBTAIN Investigators of European Society of Anaesthesiology (ESA) Clinical Trial Network. Prospective observational cohort study of the association between antiplatelet therapy, bleeding and thrombosis in patients with coronary stents undergoing noncardiac surgery. Br J Anaesth. 2019;122:170–179.
48. Motoyama S, Ito H, Sarai M, et al. Plaque characterization by coronary computed tomography angiography and the likelihood of acute coronary events in mid-term follow-up. J Am Coll Cardiol. 2015;66:337–346.
49. Neumann FJ, Sousa-Uva M, Ahlsson A, et al.; ESC Scientific Document Group. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40:87–165.
50. Serruys PW, Morice MC, Kappetein AP, et al.; SYNTAX Investigators. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360:961–972.
51. Thomsen C, Abdulla J. Characteristics of high-risk coronary plaques identified by computed tomographic angiography and associated prognosis: a systematic review and meta-analysis. Eur Heart J Cardiovasc Imaging. 2016;17:120–129.
52. Anwaruddin S, Askari AT, Saudye H, et al. Characterization of post-operative risk associated with prior drug-eluting stent use. JACC Cardiovasc Interv. 2009;2:542–549.
53. Armstrong EJ, Graham L, Waldo SW, Valle JA, Maddox TM, Hawn MT. Patient and lesion-specific characteristics predict risk of major adverse cardiovascular events among patients with previous percutaneous coronary intervention undergoing noncardiac surgery. Catheter Cardiovasc Interv. 2017;89:617–627.
54. Holmes DR Jr, Kereiakes DJ, Garg S, et al. Stent thrombosis. J Am Coll Cardiol. 2010;56:1357–1365.
55. van Werkum JW, Heestermans AA, Zomer AC, et al. Predictors of coronary stent thrombosis: the Dutch stent thrombosis registry. J Am Coll Cardiol. 2009;53:1399–1409.
56. Giustino G, Chieffo A, Palmerini T, et al. Efficacy and safety of dual antiplatelet therapy after complex PCI. J Am Coll Cardiol. 2016;68:1851–1864.
57. Yeh RW, Kereiakes DJ, Steg PG, et al.; DAPT Study Investigators. Lesion complexity and outcomes of extended dual antiplatelet therapy after percutaneous coronary intervention. J Am Coll Cardiol. 2017;70:2213–2223.
58. Beinart R, Abu Sham’a R, Segev A, et al. The incidence and clinical predictors of early stent thrombosis in patients with acute coronary syndrome. Am Heart J. 2010;159:118–124.
59. Dangas GD, Claessen BE, Mehran R, et al. Development and validation of a stent thrombosis risk score in patients with acute coronary syndromes. JACC Cardiovasc Interv. 2012;5:1097–1105.
60. Wallentin L, Becker RC, Budaj A, et al.; PLATO Investigators. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009;361:1045–1057.
61. Daemen J, Wenaweser P, Tsuchida K, et al. Early and late coronary stent thrombosis of sirolimus-eluting and paclitaxel-eluting stents in routine clinical practice: data from a large two-institutional cohort study. Lancet. 2007;369:667–678.
62. van Werkum JW, Heestermans AA, de Korte FI, et al. Long-term clinical outcome after a first angiographically confirmed coronary stent thrombosis: an analysis of 431 cases. Circulation. 2009;119:828–834.
63. Albaladejo P, Marret E, Samama CM, et al. Non-cardiac surgery in patients with coronary stents: the RECO study. Heart. 2011;97:1566–1572.
64. Dangas GD, Caixeta A, Mehran R, et al.; Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) Trial Investigators. Frequency and predictors of stent thrombosis after percutaneous coronary intervention in acute myocardial infarction. Circulation. 2011;123:1745–1756.
65. Hawn MT, Graham LA, Richman JS, Itani KM, Henderson WG, Maddox TM. Risk of major adverse cardiac events following noncardiac surgery in patients with coronary stents. JAMA. 2013;310:1462–1472.
66. Altoukhi RM, Alshouimi RA, Al Rammah SM, et al. Safety and efficacy of dual versus triple antithrombotic therapy (DAT vs TAT) in patients with atrial fibrillation following a PCI: a systematic review and network meta-analysis. BMJ Open. 2020;10:e036138.
67. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation. 2019;140:e125–e151.
68. Forsyth R, Sun ZH, Reid C, Moorin R. Inter-hospital transfers and door-to-balloon times for STEMI: a single centre cohort study. J Geriatr Cardiol. 2020;17:321–329.
69. Martin L, Murphy M, Scanlon A, Naismith C, Clark D, Farouque O. Timely treatment for acute myocardial infarction and health outcomes: an integrative review of the literature. Aust Crit Care. 2014;27:111–118.
70. Ong ME, Wong AS, Seet CM, et al. Nationwide improvement of door-to-balloon times in patients with acute ST-segment elevation myocardial infarction requiring primary percutaneous coronary intervention with out-of-hospital 12-lead ECG recording and transmission. Ann Emerg Med. 2013;61:339–347.
71. De Luca G, Suryapranata H, Ottervanger JP, Antman EM. Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts. Circulation. 2004;109:1223–1225.
72. Bradley EH, Nallamothu BK, Herrin J, et al. National efforts to improve door-to-balloon time results from the Door-to-Balloon alliance. J Am Coll Cardiol. 2009;54:2423–2429.
73. Chew DP, Aroney CN, Aylward PE, et al. 2011 Addendum to the National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines for the management of acute coronary syndromes (ACS) 2006. Heart Lung Circ. 2011;20:487–502.
74. Dehmer GJ, Blankenship JC, Cilingiroglu M, et al. SCAI/ACC/AHA expert consensus document: 2014 update on percutaneous coronary intervention without on-site surgical backup. Circulation. 2014;129:2610–2626.
75. Berglas NF, Battistelli MF, Nicholson WK, Sobota M, Urman RD, Roberts SCM. The effect of facility characteristics on patient safety, patient experience, and service availability for procedures in non-hospital-affiliated outpatient settings: a systematic review. PLoS One. 2018;13:e0190975.