Early Stent Thrombosis

Abstract

For 2 decades, coronary artery stents were introduced into clinical practice with 2 objectives in mind: to attenuate restenosis on the one hand and to prevent or treat abrupt vessel closure on the other. The first elective coronary stent implantation was performed in March 1986 by Jacques Puel, MD, to treat restenosis after plain balloon angioplasty. The first bail-out stenting procedure was carried out only a few months later by Ulrich Sigwart, MD, who successfully sealed an occlusive dissection. Although both groundbreaking procedures were performed in very different clinical settings, neither cardiologist, fortunately, encountered significant problems during the periprocedural period; otherwise, coronary stenting would have been doomed to failure. It took only a few more cases until an unanticipated bane of coronary stenting became noticeable: stent thrombosis. Aggressive antithrombotic regimens were sought as remedy, and aspirin was given in conjunction with dipyridamole, sulfapyrazone, and oral anticoagulation (acenocoumarin) for up to 6 months. Despite these measures, the initial experience with the self-expanding Wallstent was overshadowed by unacceptably high rates of stent thrombosis, approaching 24%, as well as bleeding complications.1 Subsequent series with the Palmaz-Schatz and Gianturco-Roubin stent, still mainly in the setting of bailout stenting, continued to result in stent thrombosis in 6% to 12% of cases.2,3 Article p 687 The advent of dual antiplatelet therapy with aspirin and the thienopyridine ticlopidine in concert with an expansion of the indication of coronary stenting from bailout procedures to elective cases resulted in a significant reduction of stent thrombosis, to <2%, as well as fewer bleeding complications.4,5 Moreover, recognition of the importance of stent implantation technique,6 appropriate pretreatment and loading with thienopyridines, and the use of glycoprotein IIb/IIIa antagonists in the setting of acute coronary syndromes led to a further decline in stent thrombosis. At the end of the …