Incidence Of Acute Stent Thrombosis Research Articles

Akut koroner sendromda akut stent trombozunun ve hastane içi mortalitenin yeni bir inflamasyon göstergesi: çoklu inflamasyon indeksi

Aim: The inflammatory milieu plays a triggering role in the development of acute stent thrombosis (ST), which occurs as a catastrophic complication following percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS). This study aimed to investigate the prognostic role of multi-inflammatory index (MII), a powerful new marker of inflammation, in predicting of high SYNTAX score, acute ST and in-hospital mortality in patients with ACS undergoing PCI.
 Material and Method: This retrospective study included 1488 consecutive patients with ACS undergoing PCI, and definitive ST was determined according to Academic Research Consortium criteria. Inflammation indices were calculated as follows: Systemic immune inflammation (SII)=neutrophil×platelet/lymphocyte ratio, CAR=CRP/albumin ratio, MII-1=platelet×CRP/lymphocyte ratio, MII-2=neutrophil×CRP/lymphocyte ratio, MII-3=SII×CRP.
 Results: The incidence of acute ST was 3.6%. All inflammation indices was higher in the acute ST group and high SYNTAX score group. Multivariable regression analysis showed that MII-3 independent predictors of acute ST and high SYNTAX score. MII-3 exhibited better diagnostic performance than other inflammatory indices. The threshold value of MII-3 in predicting acute ST was >9084 (AUC=0.842, sensitivity=87.3%, specificity=%77.8) and patients with MII-3 >9084 had a 3.73-fold greater risk of mortality. 
 Conclusion: MII-3 is a stronger predictor of acute ST following PCI and it is associated with an increased risk of mortality. MII may be an essential prognostic screening tool for identifying high-risk patients prior to procedure.

Effects of Bailout Tirofiban on In-Hospital Outcomes and Long-Term Mortality in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Intervention.

We retrospectively analyzed short- and long-term outcomes of patients who received bailout tirofiban during primary percutaneous intervention (pPCI). A total of 2681patients who underwent pPCI between 2009 and 2014 were analyzed; 1331 (49.6%) out of 2681 patients received bailout tirofiban. Using propensity score matching, 2100 patients (1050 patient received bail-out tirofiban) with similar preprocedural characteristics were identified. Patients who received bailout tirofiban had a significantly higher incidence of acute stent thrombosis, myocardial infarction, and major cardiac or cerebrovascular events during the in-hospital period. There were numerically fewer deaths in the bailout tirofiban group in the unmatched cohort (1.7% vs 2.5%, P = .118). In the matched cohort, in-hospital mortality was significantly lower (1.1% vs 2.4%, P = .03), and survival at 12 and 60 months were higher (96.9% vs 95.2%, P = .056 for 12 months and 95.1% vs 92.0%, P = .01 for 60 months) in the bailout tirofiban group. After multivariate adjustment, bailout tirofiban was associated with a lower mortality at 12 months (odds ratio [OR]: 0.554, 95% confidence interval [CI], 0.349-0.880, P = .012) and 60 months (OR: 0.595, 95% CI, 0.413-0.859, P = .006). In conclusion, bailout tirofiban strategy during pPCI is associated with a lower short- and long-term mortality, although in-hospital complications were more frequent.

Peripheral Stent Thrombosis Leading to Acute Limb Ischemia and Major Amputation: Incidence and Risk Factors in the Aortoiliac and Femoropopliteal Arteries

PurposeTo report the real-world incidence and risk factors of stent thrombosis in the aortoiliac and femoropopliteal arteries in case of bare nitinol stent (BNS) or covered nitinol stent (CNS) placement from a single-centre retrospective audit.Materials and MethodsMedical records of consecutive patients treated with peripheral stent placement for claudication or critical limb ischemia were audited for definite stent thrombosis defined as imaging confirmed stent thrombosis that presented as acute limb-threatening ischemia. Cases were stratified between aortoiliac and femoropopliteal anatomy. Cox regression analysis was employed to adjust for baseline clinical and procedural confounders and identify predictors of stent thrombosis and major limb loss.Results256 patients (n = 277 limbs) were analysed over a 5-year period (2009–2014) including 117 aortoiliac stents (34 CNS; 12.8 ± 5.0 cm and 83 BNS; 7.8 ± 4.0 cm) and 160 femoropopliteal ones (60 CNS; 21.1 ± 11.0 cm and 100 BNS; 17.5 ± 11.9 cm). Median follow-up was 1 year. Overall stent thrombosis rate was 6.1% (17/277) after a median of 43 days (range 2–192 days) and affected almost exclusively the femoropopliteal segment (12/60 in the CNS cohort vs. 4/100 in the BNS; p = 0.001). Annualized stent thrombosis rates (per 100 person-years) were 12.5% in case of CNS and 1.4% in case of BNS (HR 6.3, 95% CI 2.4–17.9; p = 0.0002). Corresponding major amputations rates were 8.7 and 2.5%, respectively (HR 4.5, 95% CI 2.7–27.9; p = 0.0006). On multivariable analysis, critical leg ischemia and CNS placement were the only predictors of stent thrombosis. Diabetes, critical leg ischemia, femoropopliteal anatomy, long stents and CNS were independent predictors of major amputations.ConclusionsPlacement of long femoropopliteal covered nitinol stents is associated with an increased incidence of acute stent thrombosis and ensuing major amputation. Risks are significantly lower in the aortoiliac vessels and with use of bare nitinol stents.

Prolonged High-Dose Bivalirudin Infusion Reduces Major Bleeding Without Increasing Stent Thrombosis in Patients Undergoing Primary Percutaneous Coronary Intervention: Novel Insights From an Updated Meta-Analysis.

BackgroundThe optimal antithrombotic therapy in patients with ST‐segment‐elevation myocardial infarction undergoing primary percutaneous coronary intervention (PCI) remains a matter of debate. This updated meta‐analysis investigated the impact of (1) bivalirudin (with and without prolonged infusion) and (2) prolonged PCI‐dose (1.75 mg/hg per hour) bivalirudin infusion compared with conventional antithrombotic therapy on clinical outcomes in patients undergoing primary PCI.Methods and ResultsEligible randomized trials were searched through MEDLINE, EMBASE, Cochrane database, and proceedings of major congresses. Prespecified outcomes were major bleeding (thrombolysis in myocardial infarction major and Bleeding Academic Research Consortium 3–5), acute stent thrombosis, as well as all‐cause and cardiac mortality at 30 days. Six randomized trials (n=17 294) were included. Bivalirudin compared with heparin (+/− glycoprotein‐IIb/IIIa inhibitor) was associated with reduction in major bleeding (odds ratio [OR]: 0.65, 95% CI: 0.48–0.88, P=0.006, derived from all 6 trials), increase in acute stent thrombosis (OR: 2.75, 95% CI: 1.46–5.18, P=0.002, 5 trials), and lower rate of all‐cause mortality (OR: 0.81, 95% CI: 0.67–0.98, P=0.03, 6 trials) as well as cardiac mortality (OR: 0.69, 95% CI: 0.55–0.87, P=0.001, 5 trials). The incidence of acute stent thrombosis did not differ between the prolonged PCI‐dose bivalirudin and comparator group (OR: 0.81, 95% CI: 0.27–2.46, P=0.71, 3 trials), whereas the risk of bleeding was reduced despite treatment with high‐dose bivalirudin infusion (OR: 0.28, 95% CI: 0.13–0.60, P=0.001, 3 trials).ConclusionsBivalirudin (with and without prolonged infusion) compared with conventional antithrombotic therapy in ST‐segment‐elevation myocardial infarction patients undergoing primary PCI reduces major bleeding and death, but increases the rate of acute stent thrombosis. However, prolonging the bivalirudin infusion at PCI‐dose (1.75 mg/kg per hour) for 3 hours eliminates the excess risk of acute stent thrombosis, while maintaining the bleeding benefits.

Bivalirudin in patients undergoing primary percutaneous coronary intervention for acute ST-elevation myocardial infarction: outcomes in a large real-world population

Within a clinical trial population, direct thrombin inhibition using bivalirudin in patients undergoing primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is associated with a reduction in mortality and major bleeding compared to heparin/glycoprotein IIb/IIIa receptor inhibition (GPI), but a higher incidence of acute stent thrombosis (ST), particularly in the absence of pre-procedural heparin. The safety and efficacy of bivalirudin in an all-comer, real-world primary PCI setting is unknown. 968 consecutive STEMI patients (mean age 63 years, 72% male, 42% anterior STEMI, 3.7% cardiogenic shock) undergoing primary PCI with bivalirudin as the recommended anticoagulation, and with heparin/GPI (abciximab) as an alternative, were prospectively followed. Bivalirudin was administered as a bolus, high-dose procedural infusion and, unlike the HORIZONS-AMI trial, as a low-dose infusion for four hours post-PCI. Additional heparin was not routinely given. Mortality, major adverse cardiovascular events (MACE), major bleeding and ST were assessed at 30 days. Initial antithrombotic therapy was bivalirudin in 885 patients (91%), of whom 123 (13.9%) received additional antithrombin therapy, and 114 (11.8%) "bail-out" GPI. Outcomes for bivalirudin-treated patients were; mortality 5.2%, MACE 7.5%, major bleeding 3.8%. The incidence of acute ST was 1.0%, including in the absence of additional heparin (1.2%). Most cases of acute ST (7/9) occurred in the first four hours post-PCI. There was no significant difference in outcomes between patients treated with bivalirudin versus heparin/GPI. Routine use of bivalirudin in a real-world primary PCI population was associated with good 30-day outcomes. Acute stent thrombosis was infrequent, even without additional heparin. A continued low-dose infusion of bivalirudin did not appear to offer protection against very early stent thrombosis.

29 Bivalirudin in patients undergoing primary percutaneous coronary intervention for acute ST-elevation myocardial infarction: outcomes in a large real-world UK population

BackgroundThe HORIZONS-AMI trial demonstrated a significantly lower early and late mortality in patients undergoing primary PCI (PPCI) treated with bivalirudin compared to a Glycoprotein IIb/IIIa inhibitor (GPI) + heparin. However,...

Acute Stent Thrombosis: Rare but Still There

curring in the first 24 hours), subacute (occurring in the first 30 days after the procedure), and late (occurring more than 30 days after the procedure), with stent thromboses occurring in the first month sometimes called ‘early’ and those occurring after more that one year sometimes called ‘very late.’ In the early days of stenting, the incidence of early stent thrombosis was very high, as patients were predominantly treated with anticoagulants. The use of dual antiplatelet therapy and high pressure stent balloon inflation have markedly decreased the occurrence of stent thrombosis. 2 The incidence of acute stent thrombosis ranges from 0.5–1.4% in bare metal stent studies 2–4 and is similar in more recent drug-eluting stent studies. 5 Although the incidence is low, the consequences are oftentimes dire with a majority of patients presenting with large myocardial infarctions, but also with sudden death. It is important to identify patients at risk and to have a high index of suspicion when evaluating patients who have undergone percutaneous coronary revascularization presenting with acute coronary syndromes. Despite its low incidence, acute stent thrombosis is a serious concern given the overall high number of patients undergoing percutaneous revascularization. The patients with acute stent thrombosis often present with myocardial infarction with high thrombus burden, as well as electrical and hemodynamic instability. Despite restoration of flow, these patients will often have refractory angina, need repeat percutaneous or surgical revascularization, and up to 20% will die in the hospital. 3 Several patient factors can lead to an increased predisposition for stent thrombosis. These include presentation with acute myocardial infarction, older age, diabetes mellitus, renal insufficiency, and low left ventricular systolic function. Bifurcation lesions, residual vessel dissection, residual thrombus, and inadequate stent apposition are procedural factors associated with acute/early stent thrombosis. 3

Et Tu, Bare Metal Stent?

When performing percutaneous coronary revascularization, physicians nearly always supplement balloon angioplasty with a stent.1 This decision is based on evidence that stent implantation enhances the procedural success and durability of angioplasty. Benefits of stenting, compared with balloon angioplasty, include a reduction in the incidence of lesion recurrence, manifested as reduced need for repeat revascularization and lower rates of periprocedural myocardial infarction (MI).2–5 The major shortcoming of bare metal stents (BMS) is that ≈20% of native vessel and 30% of saphenous vein graft patients develop angiographic restenosis from neointimal hyperplasia. About half of these patients will have clinical restenosis and require repeat revascularization. In contrast to the favorable results of stents in de novo lesions, stenting of in-stent restenotic lesions with BMS results in more restenosis. Before the drug-eluting stent (DES) era, of multiple therapies investigated, only intracoronary brachytherapy was effective in preventing recurrent in-stent restenosis.6,7 Article p 2391 Fortunately, the DES was developed to suppress neointimal hyperplasia, and several randomized, double-blind, clinical trials demonstrated the ability of DES to substantially reduce the incidence of in-stent restenosis.8–10 Within a short time after commercialization, DES nearly replaced BMS in the United States, and the number of patients requiring repeat revascularization fell substantially.1 As clinical restenosis became infrequent, another potential and untoward event related to stents became more exposed—namely, stent thrombosis. This disorder can cause abrupt coronary occlusion and frequently clinically manifests as acute MI or death. Although stent thrombosis was common during the early years of BMS use, improvements in the technique of stent implantation and the administration of both aspirin and a thienopyridine (dual antiplatelet therapy) reduced the incidence of acute stent thrombosis to clinically acceptable levels.11,12 More recently, …

New imaging methods for visualizing coronary arteries

Techniques in the field of coronary artery imaging can be divided into two groups: invasive and non-invasive methods. Apart from the conventional coronary artery angiography, invasive methods include intracoronary ultrasound, intracoronary angioscopy, and optical coherence tomography. Non-invasive methods include magnetic resonance tomography, synchrotron-coronary angiography, and electron beam computed tomography. In the late 1980s, intracoronary ultrasound has come into clinical practice. It offers a real-time, cross-sectional image of the coronary artery in high resolution. Coronary arteries enlarge in the presence of atherosclerotic plaque formation in order to compensate for luminal narrowing caused by plaque formation (remodeling). With coronary angiography, the plaque formation cannot be detected until a lumen reduction of about 40-45%. With intravascular ultrasound, the early stages of atherosclerosis can clearly be demonstrated. In combination with the intracoronary Doppler technique, syndrome X can be differentiated. Another important role of intracoronary ultrasound in the diagnosis of coronary artery disease is to guide coronary interventions and to assess the result of coronary interventions especially to evaluate the result of stent implantation. Due to the clinical use of intracoronary ultrasound and the guidance of high pressure stent implantation, the incidence of acute stent thrombosis has decreased to about 1%. Coronary angioscopy portrays the surface of the vessel lumen. It is helpful to identify the mural thrombus especially to differentiate fresh and chronic thrombus formation. Magnetic resonance tomography is able to image the coronary arterial contour of the proximal segment. With today's gating technique, it is possible to portray the whole coronary tree and avoid disturbances resulting from the heart beat and respiration. Electron beam computed tomography is a very promising technique in screening for coronary artery disease. It is a very sensitive method to identify coronary calcification and, thus, to detect atherosclerotic plaque. Studies have shown that the presence of calcification almost invariably indicates the presence of coronary artery disease and that the absence of calcification can nearly rule out significant coronary artery disease. Moreover, a close correlation exists between the amount of calcification and the severity of coronary artery disease. Additionally, in combination with contrast injection, coronary artery perfusion can be evaluated. This is important to assess the conductance of coronary stent and bypass graft.