Extremely late drug-eluting stent thrombosis: 2037 days after deployment

doi:10.1016/j.carrev.2008.05.001

Cardiovascular Revascularization Medicine

Volume 10, Issue 1, January–March 2009, Pages 55-57

https://doi.org/10.1016/j.carrev.2008.05.001 Get rights and content

Abstract

Thrombosis of drug eluting stents has been documented up to four years after stent implantation, often in the setting of cessation of antiplatelet therapy. We present a case of drug-eluting stent thrombosis, 2037 days after initial implantation, which we believe is the latest reported case. Late stent thrombosis remains a rare but catastrophic complication of coronary intervention. We hypothesize that the procoagulant milieu of surgery, coupled with cessation of one or both antiplatelet agents preoperatively, compounds the risk of perioperative stent thrombosis.

Section snippets

Case report

A 57-year-old man was urgently transferred to our institution with an acute anterior ST-elevation myocardial infarction (STEMI) and cardiogenic shock. He was referred from another local hospital where he had undergone an elective 4-h operation for the bony attachment of a hearing aid. In postoperative recovery, he had complained of chest pain, and electrocardiogram (ECG) revealed anterior ST elevation (Fig. 1). This was on a background of anterior STEMI 6 years previously in 2002; at that time,

Discussion

The optimum duration of dual-antiplatelet therapy post DES insertion remains controversial and undefined. Late stent thrombosis is defined as that which occurs after 30 days of intervention and is a phenomenon which is almost exclusively associated with DES [1]. Late stent thrombosis remains a rare but catastrophic complication of coronary intervention with reported mortality rates of up to 8.2% [2]. Discontinuation of dual antiplatelet therapy has been strongly associated with late stent

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Cited by (20)

Prospective observational cohort study of the association between antiplatelet therapy, bleeding and thrombosis in patients with coronary stents undergoing noncardiac surgery
2019, British Journal of Anaesthesia
Citation Excerpt :
OBTAIN included patients who had undergone PCI up to 4 yr before surgery. Whilst current guidelines recommend DAPT for up to a year after PCI, late in-stent thrombosis has been reported up to as late as 5.5 yr after PCI and the risk of in-stent thrombosis in non-surgical patients has been a cause of considerable concern.8,9,33–36 A recent meta-analysis indeed showed that continuation of DAPT for 18–48 months after PCI was associated with a decreased incidence of stent thrombosis and MI, but with an increased risk of major bleeding.37
The perioperative management of antiplatelet therapy in noncardiac surgery patients who have undergone previous percutaneous coronary intervention (PCI) remains a dilemma. Continuing dual antiplatelet therapy (DAPT) may carry a risk of bleeding, while stopping antiplatelet therapy may increase the risk of perioperative major adverse cardiovascular events (MACE).
Occurrence of Bleeding and Thrombosis during Antiplatelet Therapy In Non-Cardiac Surgery (OBTAIN) was an international prospective multicentre cohort study of perioperative antiplatelet treatment, MACE, and serious bleeding in noncardiac surgery. The incidences of MACE and bleeding were compared in patients receiving DAPT, monotherapy, and no antiplatelet therapy before surgery. Unadjusted risk ratios were calculated taking monotherapy as the baseline. The adjusted risks of bleeding and MACE were compared in patients receiving monotherapy and DAPT using propensity score matching.
A total of 917 patients were recruited and 847 were eligible for inclusion. Ninety-six patients received no antiplatelet therapy, 526 received monotherapy with aspirin, and 225 received DAPT. Thirty-two patients suffered MACE and 22 had bleeding. The unadjusted risk ratio for MACE in patients receiving DAPT compared with monotherapy was 1.9 (0.93–3.88), P=0.08. There was no difference in MACE between no antiplatelet treatment and monotherapy 1.03 (0.31–3.46), P=0.96. Bleeding was more frequent with DAPT 6.55 (2.3–17.96) P=0.0002. In a propensity matched analysis of 177 patients who received DAPT and 177 monotherapy patients, the risk ratio for MACE with DAPT was 1.83 (0.69–4.85), P=0.32. The risk of bleeding was significantly greater in the DAPT group 4.00 (1.15–13.93), P=0.031.
OBTAIN showed an increased risk of bleeding with DAPT and found no evidence for protective effects of DAPT from perioperative MACE in patients who have undergone previous PCI.
Very very late stent thrombosis: 9.5 years after DES implantation
2016, Indian Heart Journal
Citation Excerpt :
VLST is extremely rare after five years of stent implantation. The first case was reported in 2009.3 A new term “very (or extreme) very late stent thrombosis (VVLST)” was suggested when ST occurred after five years of stent implantation.
Very late stent thrombosis (VLST) has been recognized as a class effect of 1st generation drug eluting stents (DES) implantation. Although rare, VLST has been reported between 1 and 4 years after DES implantation. Very very late stent thrombosis (VVLST) occurring more than 5 years after DES implantation is extremely rare. We report the first case of a VVLST from India occurring 3465 days (9.5 years) after DES implantation with a brief discussion on its pathogenesis and prevention.
The resting status of the coronary microcirculation is a predictor of microcirculatory function following elective PCI for stable angina
2013, International Journal of Cardiology
Citation Excerpt :
The model included variables such as HbA1C, fasting glucose, ADMA, stent length—and number, baseline transit time, coronary wedge pressure, inflation number and IMR measured pre PCI. The model performed reasonably well with an R [2] of 0.45 (p = 0.005). Of the variables included in the model, only IMR measured pre PCI (Beta = 0.47, p = 0.002) and baseline transit time (Beta = 0.28, p = 0.04) were independent predictors of post PCI IMR.
We performed a prospective study to investigate markers of percutaneous coronary intervention (PCI) related microvascular injury.
Consecutive patients undergoing PCI for stable angina were studied. The index of microvascular resistance (IMR) was measured using a temperature and pressure sensing guidewire (TPSG) before and after single vessel PCI. Basal transit-time (Tmn_Base), that reflected non-hyperemic blood flow was also measured. Fasting bloods were taken to measure blood sugar, HbA1c and lipids. Asymmetric dimethylarginine (ADMA) was also measured as a marker of systemic endothelial function.
55 patients were included in the study. Mean age was 59.9 ± 11.2, 74.1% male. There was no significant difference in IMR post PCI compared with pre PCI values (IMR pre PCI = 16.96 [11.5,25.38] vs. IMR post PCI 14.2 [10.37,26.25] p = 0.96). IMR post PCI was higher in diabetic (DM) patients compared with non-diabetics [IMR post DM = 22.72 (13.35,42.91) vs. no DM = 13.9 (10.18,21.45), p = 0.02]. Fasting blood sugar, HbA1c and IMR pre PCI were correlated with post PCI IMR. IMR pre PCI, HbA1C and fasting glucose were higher in patients who developed PCI related microvascular dysfunction. The strongest independent predictor of post PCI IMR was the pre PCI IMR.
The baseline status of the microcirculation is an important determinant of post PCI microvascular function. Diabetics appear to have higher post PCI IMR.
Proximal atherosclerotic lesion as a cause of very late stent thrombosis
2011, Medical Hypotheses
Citation Excerpt :
From the advent of balloon angioplasty to the current use of drug eluting stents, thrombosis in the intervened segment has been a dreaded complication. Recently, DES have been criticized for events of stent thrombosis occurring anywhere from 1 to 5 years after implantation [9–13]. This is of particular interest, and in this article we are proposing a hypothesis that will add to the known risk factors of stent thrombosis.
Very late stent thrombosis is defined as in-stent thrombosis occurring after 1 year of an intra-coronary artery stent placement. Drug eluting stents have lately been criticized for increased reports of very late stent thrombosis. The exact cause of these very late stent thromboses is not clearly understood. Virchow’s triad describes the three main factors of thrombus formation to be stasis of blood flow, endothelial injury and hypercoagulability. Based on Virchow’s triad, we propose the cause of very late stent thrombosis to be formation of a de novo atherosclerotic lesion in the proximal segment of a stented artery. The de novo atherosclerotic lesion narrows the vessel lumen and causes stasis of blood flow in the distal stent. The de novo lesion can also cause myocardial ischemia creating a prothrombotic environment in the stented region. Stasis of blood flow and prothrombotic environment in the stented region can lead to the formation of very late stent thrombosis. Since atherosclerosis is a dynamic aging process in humans, we propose de novo proximal lesions in the coronary arteries can predispose to very late stent thrombosis.
Contemporary approaches to perioperative management of coronary stents and to preoperative coronary revascularization: A survey of 374 interventional cardiologists
2011, Cardiovascular Revascularization Medicine
We sought to assess contemporary approaches of interventional cardiologists to preoperative evaluation and perioperative management of coronary stents.
Online survey sent in December 2008 to 3771 US interventional cardiologists (10% completion rate).
Patients with coronary stents needing noncardiac surgery are frequently encountered: 49% and 30% of the cardiologists saw two to four and five or more such patients, respectively, every month. The majority of participants recommended (a) ≥6 weeks delay as optimal for surgery after bare metal stent implantation; (b) continuing dual antiplatelet therapy in stent patients undergoing minor bleeding risk procedure; (c) avoiding drug-eluting stent implantation in patients known to need noncardiac surgery within 12 months from percutaneous coronary intervention; (d) treating perioperative stent thrombosis with primary percutaneous coronary intervention; and (e) performing nuclear stress testing in stable patients who need major noncardiac surgery. There was equipoise in the need for “bridging” with glycoprotein IIb/IIIa inhibitors in patients needing early surgery after drug-eluting stent implantation.
Interventional cardiologists frequently treat patients who require surgery after stent implantation. Although agreement exists on the optimum delay for surgery after stenting, on the need for bare metal stents or balloon angioplasty alone if early noncardiac surgery is needed, and on the treatment of perioperative stent thrombosis, there is divergence of opinion on the need for preoperative stress testing and on the “bridging” therapy for patients who need surgery early after stent implantation.
Optical coherence tomographic insights of very late stent thrombosis of a second-generation drug-eluting stent: A case report
2021, European Heart Journal - Case Reports

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Images and Case Reports in Interventional CardiologyExtremely late drug-eluting stent thrombosis: 2037 days after deployment

Abstract

Section snippets

Case report

Discussion

Lancet

J Thromb Haemost

Images and Case Reports in Interventional Cardiology
Extremely late drug-eluting stent thrombosis: 2037 days after deployment