Discontinuation of preoperative clopidogrel is unnecessary in peripheral arterial surgery

Abstract

Objective: The optimal management of preoperative clopidogrel remains controversial, as vascular surgeons are increasingly encountering patients treated with clopidogrel as part of dual antiplatelet therapy. Current practice differs considerably, from cessation of the medication at least 5 days before surgery to proceeding with surgery without delay. The purpose of this prospective, nonrandomized, comparative study was to determine the effect of preoperative exposure to clopidogrel and aspirin on perioperative bleeding complications in patients undergoing open arterial surgery.

Methods: Data were collected prospectively on 647 consecutive major arterial procedures from 2005 through mid-2012. Patients were classified into two groups: the clopidogrel group consisted of 305 procedures performed in 269 patients who were maintained, after obtaining informed consent, on dual clopidogrel and aspirin up to the time of surgery and the no-clopidogrel group consisted of 342 procedures completed in 298 patients who were taking neither medication together or were taking aspirin alone. The primary composite end point was reoperation for bleeding and bleeding-related death. Secondary end points included blood transfusion requirements, hematoma formation, the procedure duration, as well as hospital and intensive care unit length of stay.

Results: The patients taking clopidogrel had a higher cardiovascular risk profile and a higher prevalence of prior peripheral and coronary stents (P < .0001). Clopidogrel use was common across all operation categories: 59% of carotid endarterectomy patients (104 of 177), 43% of lower extremity bypass patients (147 of 344), and 43% of abdominal aortic bypass patients (54 of 126). The difference in the primary end point between the clopidogrel and no-clopidogrel groups was not statistically significant (0.65% and 0.3%, respectively; P =.55). No bleeding-related deaths were observed. Further analysis revealed a similar incidence of stable hematomas. Blood transfusions were mainly required by patients undergoing aortic surgery, at similar rates and volumes in the clopidogrel and no-clopidogrel groups: abdominal aortic bypass cohort (a mean of 1.6 units packed red blood cells needed in 72% vs a mean of 1.6 units in 69%, respectively; P =.76); lower extremity bypass cohort (a mean of 1.5 units needed in 15% vs 1.3 units needed in 11%; P < .004). The mean operative time and intensive care unit and hospital lengths of stay were not longer in clopidogrel recipients.

Conclusions: Combined therapy with clopidogrel and aspirin up to the day of surgery is not associated with increased bleeding complications or transfusion requirements. Data from this study do not validate the perceived higher risk of perioperative bleeding in clopidogrel patients and do support the strategy of continued clopidogrel use in patients undergoing peripheral arterial surgery.