In response to What is the optimal perioperative management of antiplatelet therapy?

We thank Drs. Partington, Woodworth, and Harrigan for their letter. We wholeheartedly agree with their sentiment that surgeons must balance patients’ thromboembolic risks and bleeding risk on a case-by-case basis when deciding the optimal perioperative management of antiplatelet therapy, and that this complex decision is best made in conjunction with other physicians intimately involved in the patient’s medical care, including the physician or service that placed the patient’s stent(s), if applicable. Specifically, our best practice recommendation emphasized throughout the article was that “The decision to interrupt antiplatelet therapy must balance the patient’s thromboembolic risk and perioperative bleeding risk and is therefore best made in conjunction with the patient’s cardiologist and anesthesiologist.” We disagree with Partington, et al.’s notion that an analysis of thromboembolic complications during interruption of antiplatelet therapy, particularly in patients with stents, was absent in our Best Practice review. In fact, our Triological Society Best Practice (TrioBP) separately considers perioperative management of antiplatelet therapy in patients with and without stents. We gave specific consideration to patients with stents on dual antiplatelet therapy. Major thromboembolic events were primary outcomes of three of the four studies that we referenced, and these are highlighted in the main findings of Table 1. Although Partington, et al. is correct in observing that the randomized trial on perioperative aspirin management has a small proportion of patients with stents, our discussion on patients with stents focuses on two large studies conducted specifically on outcomes of surgery in patients with coronary stents. Therefore, for patients without stents and with low overall thromboembolic risk, we consider the recommendation to discontinue aspirin to indeed be conservative; however, as stated in the sentences immediately following that which Partington, et al. isolated from context, our recommendations for patients with higher thromboembolic risks are different and echo the latest guidelines of the American College of Cardiology/American Heart Association and American College of Chest Physicians. With regard to carotid, vertebral, and intracranial stents and stenosis, the same philosophy of balancing thromboembolic risks and bleeding risk applies. The findings of Hwang et al.’s study on stent-assisted coil placement in cerebral aneurysm, cited by Partington, et al., parallels the findings of Van Kuijk et al. referenced in our TrioBP, showing decreasing thromboembolic risk in stented patients with increasing time between stenting and surgery, allowing stents to endothelialize. Additionally, Maulaz et al.’s study cited by Partington, et al. found coronary artery disease to be the only major risk factor for brain ischemia after aspirin discontinuation. Thus, we believe we were justified in limiting discussion of special cases to coronary artery disease and leaving additional caveats open to case-based decisions, as recommended. Finally, the small study on flow-diverting stents and anecdotal evidence that Partington, et al. describes are important considerations to factor into these casebased decisions, highlighting our closing recommendation that higher quality “Prospective studies on perioperative antiplatelet management, stratifying otolaryngological procedures by bleeding risk, are necessary to further guide individual recommendations.”