Late Drug-eluting Stent Thrombosis Research Articles

Mechanisms of Very Late Stent Thrombosis in Japanese Patients as Assessed by Optical Coherence Tomography

BackgroundAlthough very late stent thrombosis (VLST) remains an important concern, the underlying etiology and clinical characteristics are not fully elucidated in Japanese patients who undergo intravascular imaging-guided percutaneous coronary intervention (PCI) regularly. MethodsWe identified 50 VLST lesions (bare-metal stent [BMS] [n = 16], first-generation drug-eluting stent [DES] [n = 14] and newer-generation DES [n = 20]) in patients managed in our institutes. The underlying mechanism of VLST was assessed by optical coherence tomography (OCT), and the major etiology of each lesion was determined. The aim of this study was to explore the mechanisms of VLST of BMSs and DESs in Japanese patients. ResultsThe median duration since stent implantation was 10 years (range: 1-20). The most frequent etiology of VLST was neoatherosclerotic rupture (44%), followed by neointimal erosion (24%). Edge disease (10%) and evagination (10%) were similarly observed. Malapposition (8%) was deemed to be acquired late by looking at intravascular imaging from the index procedure. Uncovered struts (2%) and in-stent calcified nodule (2%) were the least frequent etiologies. Regardless of etiology, signs of neoatherosclerosis were present in most lesions (82%). Most patients received single (68%) or dual (8%) antiplatelet therapy or oral anticoagulation alone (4%), whereas a considerable proportion of patients discontinued medication (20%). Regarding the treatment strategy, drug-coated balloon was the most frequent strategy (56%), followed by implantation of newer DESs (34%). ConclusionsVarious mechanisms have been identified in Japanese patients with VLST. In these patients, biological responses seemed to be more relevant than the index procedure-related factors.

Late Coronary Stent Thrombosis in a Patient With Coronavirus Disease 2019

This case report describes a patient with coronavirus disease 2019 who developed late drug-eluting stent thrombosis.

Near-infrared spectroscopy, optical coherence tomography and angioscopy to unravel the mechanism of very late metallic drug-eluting stent thrombosis.

Near-infrared spectroscopy, optical coherence tomography and angioscopy to unravel the mechanism of very late metallic drug-eluting stent thrombosis.

P2333Characteristics of earlier versus delayed presentation of very late drug-eluting stent thrombosis: an optical coherence tomographic study

P2333Characteristics of earlier versus delayed presentation of very late drug-eluting stent thrombosis: an optical coherence tomographic study

Trends in Bare-Metal Stent Use in the United States in Patients Aged ≥65 Years (from the CathPCI Registry)

In 2006, the United States (US) Food and Drug Administration published advisory highlighting concerns for late drug-eluting stent thrombosis; its impact on US bare-metal stent (BMS) utilization is unknown. We examined rates of BMS use among Medicare patients at 946 US hospitals in the CathPCI Registry who underwent percutaneous coronary intervention (PCI) during 3 periods: (1) 2004 to 2006 preadvisory (n= 166,458); (2) 2007 to 2008 postadvisory (n= 216,318); and (3) 2012 to 2014 contemporary (n= 827,948). We examined predicted risks of target vessel revascularization and bleeding among BMS recipients by period. We compared 1-year repeat revascularization and death/myocardial infarction risks among BMS recipients immediately preadvisory and postadvisory. BMS were used in 15.8% of preadvisory, 40.9% of postadvisory, and 20.0% of contemporary PCI procedures. Although 19.5% of preadvisory BMS patients had a predicted target vessel revascularization risk ≥15%/year, this decreased to 16.7% postadvisory (p <0.001), and increased back to 18.7% among contemporary BMS recipients (p <0.001). In contrast, 12.3% of preadvisory BMS recipients had a predicted bleeding risk ≥5%/year, compared with 14.6% postadvisory (p <0.001), and 18.2% in contemporary BMS recipients (p <0.001). Postadvisory BMS recipients had a lower risk of repeat revascularization (12.8% vs 14.6%, adjusted hazard ratio 0.87, 95% CI 0.84 to 0.90) but no difference in the composite risk of death/myocardial infarction (15.9% vs 15.9%, adjusted hazard ratio 0.97, 95% CI 0.93 to 1.00). In conclusion, a surge in BMS use after the advisory was not associated with an increased risk of repeat revascularization or adverse outcomes in BMS-treated patients. One in 5 contemporary PCI procedures still involve BMS implantation.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Mechanisms of Very Late Drug-Eluting Stent Thrombosis Assessed by Optical Coherence Tomography.

The pathomechanisms underlying very late stent thrombosis (VLST) after implantation of drug-eluting stents (DES) are incompletely understood. Using optical coherence tomography, we investigated potential causes of this adverse event. Between August 2010 and December 2014, 64 patients were investigated at the time point of VLST as part of an international optical coherence tomography registry. Optical coherence tomography pullbacks were performed after restoration of flow and analyzed at 0.4 mm. A total of 38 early- and 20 newer-generation drug-eluting stents were suitable for analysis. VLST occurred at a median of 4.7 years (interquartile range, 3.1-7.5 years). An underlying putative cause by optical coherence tomography was identified in 98% of cases. The most frequent findings were strut malapposition (34.5%), neoatherosclerosis (27.6%), uncovered struts (12.1%), and stent underexpansion (6.9%). Uncovered and malapposed struts were more frequent in thrombosed compared with nonthrombosed regions (ratio of percentages, 8.26; 95% confidence interval, 6.82-10.04; P<0.001 and 13.03; 95% confidence interval, 10.13-16.93; P<0.001, respectively). The maximal length of malapposed or uncovered struts (3.40 mm; 95% confidence interval, 2.55-4.25; versus 1.29 mm; 95% confidence interval, 0.81-1.77; P<0.001), but not the maximal or average axial malapposition distance, was greater in thrombosed compared with nonthrombosed segments. The associations of both uncovered and malapposed struts with thrombus were consistent among early- and newer-generation drug-eluting stents. The leading associated findings in VLST patients in descending order were malapposition, neoatherosclerosis, uncovered struts, and stent underexpansion without differences between patients treated with early- and new-generation drug-eluting stents. The longitudinal extension of malapposed and uncovered stent was the most important correlate of thrombus formation in VLST.

Thrombose coronaire très tardive par fracture du stent actif. Cas clinique et revue de la littérature

The superiority of drug-eluting stents in reducing the risk of in-stent restenosis compared to bare-metal stents is no longer challenged. Nevertheless, the drug-eluting stents may carry long-term risk of late and very late stent thrombosis. The promoting factors of this complication are usually divided into three chapters depending on the patient, the procedure and the stent. Indeed, the literature has reported several parameters related to the stent itself, such as its length, the malapposition, its diameter, but also more rarely the occurrence of stent fracture. We present the case of a patient admitted for myocardial infarction after a very late thrombosis of Cypher drug-eluting stent four years after its implantation and related to stent fracture.

Long-term outcomes following very late stent thrombosis of drug-eluting stent

BackgroundLong-term outcomes of very late stent thrombosis (VLST) after implantation of drug-eluting stents (DES) are still unclear. The aim was to evaluate the long-term outcomes after VLST of DES, and to analyze the related factors of long-term outcomes in these patients. MethodsFrom January 2006 to February 2013, patients with angiographically defined VLST were studied. The clinical characteristics, angiography and interventional data, and anti-platelet therapy protocols were analyzed. The patients were divided into two groups according to the occurrence of major adverse cardiac events (MACE) during follow-up. The clinical and interventional data between the two groups were compared. ResultsSixty-two patients were enrolled consisting of 55 males and 7 females with an average age of 58.6±10.2 (41–82) years. The mean time from first implantation of DES to occurrence of VLST was 38.7±18.1 (12.5–84) months. One patient died in hospital. Sixty-one patients survived to discharge, and MACE occurred in 17 patients after a median follow-up of 32.1±19.1 (median: 44, range 5–88) months. The total MACE rate was 29.0% (18/62), and Kaplan–Meier survival analysis showed the estimated MACE-free survival was 45.1%. The rate of implantation of an additional first-generation DES during the first VLST in the group with events was higher (44.4% vs.11.4%, respectively, p=0.007). The percentage of continuous dual antiplatelet therapy (DAPT) at the longest available follow-up was higher in the event-free group (27.8% vs. 75.0%, respectively, p=0.001). Multivariable Cox regression analysis revealed that the only independent predictors for freedom of MACE during long-term follow-up was continuous DAPT at the longest available follow-up [hazard ratio (HR)=0.30, 95% CI: 0.09–0.97, p=0.04]. ConclusionsLong-term outcomes after VLST were unfavorable. Implantation of an additional first-generation DES might be avoided, and DAPT should be continued.

Association of localized hypersensitivity and in-stent neoatherosclerosis with the very late drug-eluting stent thrombosis.

BackgroundLocalized hypersensitivity reaction, delayed arterial healing, and neoatherosclerosis inside the stent have been suggested as the underlying pathologic mechanisms of very late stent thrombosis (VLST) of drug-eluting stent (DES). The present study sought to explore the prevalence of inflammatory cell infiltrates and evidence for fragments of atherosclerotic plaques in the aspirated thrombi in patients with DES VLST.Methods and ResultsFrom April 2004 to September 2012, 48 patients with stent thrombosis (ST) of DES underwent thrombus aspiration with retrieved material sufficient for the histopathologic analysis; early ST (EST, within 30 days): N = 17, late ST (LST, between 31 and 365 days): N = 7, and very late ST (VLST, >1 year): N = 24. Eosinophil fraction in the aspirated thrombi was significantly higher in patients with VLST (8.2±5.7%) as compared with those with EST (4.3±3.0%) and LST (5.5±3.8%) (P = 0.03). Eosinophil fraction in the aspirated thrombi was significantly higher in 12 VLST patients with angiographic peri-stent contrast staining (PSS) and/or incomplete stent apposition (ISA) by intravascular ultrasound than in 12 VLST patients without PSS or ISA (10.6±6.1% versus 5.8±4.1%, P = 0.03). Evidences for fragments of atherosclerotic plaques in the aspirated thrombi were observed only in 3 (13%) out of 24 patients with DES VLST.ConclusionsEosinophil fraction in the aspirated thrombi was significantly higher in patients with DES VLST as compared with those with EST and LST. Evidences for fragments of atherosclerotic plaques were relatively uncommon in patients with DES VLST.

Correlates and outcomes of late and very late drug-eluting stent thrombosis: results from DESERT (International Drug-Eluting Stent Event Registry of Thrombosis).

The aim of this study was to identify clinical, procedural, and angiographic correlates of late/very late drug-eluting stent (DES) thrombosis as well as to determine the clinical outcomes of these events. Late/very late DES thromboses are a poorly studied phenomenon, partly due to the relative infrequency of these events, even in large cohort studies. In the DESERT (International Drug-Eluting Stent Event Registry of Thrombosis), a retrospective, case-control registry, 492 cases of late/very late definite DES thrombosis from 21 international sites were matched in a 1:1 fashion with controls without stent thrombosis (ST). Controls were matched according to 2 criteria: same enrolling institution and date of initial DES implantation. Baseline and procedural variables were collected, and clinical follow-up was obtained for patients with ST as long as 1 year after the event. Offline quantitative coronary angiography was performed for a subset of 378 case-control pairs. The majority of ST events occurred after 1 year (75%) and continued to occur for as long as 7.3 years. The clinical presentation of late/very late ST events was mainly myocardial infarction (66.7% ST-segment elevation myocardial infarction and 22.0% non-ST-segment elevation myocardial infarction); in-hospital mortality was 3.8%. Aminority of patients (30%) with ST were receiving dual-antiplatelet therapy at the time of the event. Independent clinical correlates of late/very late ST were younger age, African-American race, current smoking, multivessel disease, longer stented length, overlapping stents, and percutaneous coronary intervention of vein graft lesions. Independent angiographic correlates for late/very late ST were lesions within the left anterior descending artery or a bypass graft, thrombus, and a larger residual diameter stenosis after the initial DES implantation. Despite the large sample of ST cases, all identified correlates of late/very late ST had weak associations with subsequent ST (all odds ratios<2.5). Despite a large sample of ST cases and use of limited matching to maximize the identification of predictive factors associated with late/very late ST, the variables associated with the development of late/very late ST were only weakly predictive of subsequent events. Additionally, a relatively low observed mortality rate of ST in this series may reflect a different pathophysiology of these late/very late events compared with acute/subacute ST. (DrugEluting Stent Registry of Thrombosis [DESERT]; NCT00812552).

Late and very late drug-eluting stent thrombosis in the immediate postoperative period after antiplatelet withdrawal: a retrospective study.

Late (31-360 days after deployment) and very late (>360 days after deployment) stent thrombosis is a feared complication after drug-eluting stent (DES) deployment. The American College of Cardiology/American Heart Association guidelines recommend dual antiplatelet therapy for 12 months due to the lack of protection beyond this period in randomized trials. The perioperative period is a unique state of generalized hypercoagulability which can predispose people to DES thrombosis when combined with the rebound hypercoagulable effect of antiplatelet withdrawal. A retrospective chart review was performed to detect incidences of late and very late postoperative DES thrombosis after elective noncardiac surgery. Only definite and probable cases of stent thrombosis were included. All cases were analyzed for patient demographics, comorbidities, type of surgery, intervention history, preoperative antiplatelets management, postoperative course and outcome. A total of six patients with prior DES deployment (10-42 months earlier, average 30 months) developed DES thrombosis (five very late and one late) in the immediate postoperative period. All patients had stable coronary artery disease and were cleared for surgery (intermediate cardiac risk surgery) by their cardiologist. In all patients, antiplatelets were discontinued 4-7 days (average 5.6 days) prior to surgery to minimize operative bleeding. Five of six patients developed ST-segment elevation myocardial infarction. Half of the patients had simultaneous two-vessel DES thrombosis and two cases had single vessel thrombosis. Three patients developed ventricular fibrillation and cardiac arrest. One-third of the patients died during the index hospitalization. Coronary thrombectomy and angioplasty was successful in the remaining four cases. The incidence of postoperative late and very late DES thrombosis among all patients undergoing noncardiac surgery who were older than 40 years was 0.006%. Caution should be exercised when attempting to withdraw antiplatelets preoperatively in patients with DES even when the recommended 12-month period of dual antiplatelet therapy (DAPT) has elapsed. The significant morbidity and mortality of this complication warrants further research to study the ideal perioperative management of antiplatelets in patients with prior DES deployment over 1 year who are still receiving DAPT.

Post-operative simultaneous very late two-vessel drug eluting stent thrombosis with sparing of bare metal stent in a Jehovah's witness after clopidogrel withdrawal

Very late stent thrombosis is a feared complication after drug-eluting stent (DES) implantation. Several factors related to the patient, generation and type of the deployed stent, procedure, and premature antiplatelet withdrawal are known to contribute to this complication. Herein, we describe a case of a Jehovah's witness patient who developed simultaneous two-vessel 1st generation DES thrombosis 5.4 and 3.5 years after deployment [with sparing of the bare metal stent (BMS)] in the immediate post-operative period secondary to clopidogrel withdrawal. The case was complicated by ST-segment elevation myocardial infarction, cardiogenic shock, and a ventricular fibrillation cardiac arrest requiring urgent percutaneous coronary intervention. The acute thrombosis of DESs with sparing of the BMS exemplify how they are more prone to this complication due to delayed endothelialization of stent struts and neoinitimal coverage.<Learning objective: Extreme caution should be excercised when attempting to withdraw antiplatelets immediately before surgery in patients with drug eluting stents even if the recomended 12-month period of dual antiplatelet therapy has elapsed because of the risk of very late stent thrombosis.>

Recurrent very late drug-eluting stent thrombosis

Stent thrombosis (ST) is an unusual but serious complication of percutaneous coronary intervention (PCI), potentially leading to myocardial infarction and death [1]. ST is categorized by the time of occurrence after stent implantation: acute (<24h), sub-acute (<30days), late (<1year) and very late (>1year), and by the level of certainty: definite, probable and possible [2]. The mechanism of ST is often multifactorial with mechanical, allergic or pharmacological (resistance to antiplatelet therapy) causes [3].

Analysis of In-stent neoatherosclerosis after drug-eluting stent implantation using a 40 MHz intravascular ultrasound imaging system

Objectives: It reported in-stent neoatherosclerosis is a frequent finding in Drug-Eluting Stents (DES) and occurs earlier than in Bare Metal Stent (BMS) from autopsy date. But, analyses of neointimal tissue components according to the follow-up period have not been fully examined in-vivo. The aim of this study was to characterize in-stent neoatherosclerosis using radiofrequency signals from 40 MHz intravascular ultrasound (IVUS), called iMAP-IVUS. Methods: IVUS examinations were performed on 32 consecutive angina patients (32 lesions) underwent repeated PCI for the treatment of DES in-stent restenosis. We assessed neointimal tissue characteristics using iMAP-IVUS. Neointimal plaque volumes were calculated by the difference between stent and lumen volumes and coded tissue as four components; fibrous, lipidic, necrotic, and calcified. The patients were divided into two groups according to the follow-up duration: group A (≤1 year, 18 lesions) and group B (>1 year, 14 lesions). Results: Mean follow-up periods between stent implantation and repeated PCI were 21±20 months (group A: 8±2 months; group B: 37±20 months). Baseline clinical and angiographic characteristics were similar for the two groups. The percentages of fibrotic, lipidic and calcified relative volume were similar in the both group, too. However, the percentages of necrotic relative volume was greater in the group B (>1 year) than in the group A (≤1 year) (11.07% vs. 8.28%, P<0.05). ![Figure][1] Figure 1 Conclusions: These results suggest that in-stent neoatherosclerosis might be important mechanism of failure or very late stent thrombosis of DES. [1]: pending:yes

Who is at risk to develop late drug-eluting stent thrombosis while on dual antiplatelet therapy? A subset analysis from the Drug Eluting Stent Event Registry of Thrombosis (DESERT)

Who is at risk to develop late drug-eluting stent thrombosis while on dual antiplatelet therapy? A subset analysis from the Drug Eluting Stent Event Registry of Thrombosis (DESERT)

Angioscopically apparent large thrombus and uncovered stent struts 6 months after late stent thrombosis of a paclitaxel-coated nitinol drug-eluting stent implanted in the superficial femoral artery

A 74-year-old woman complained of claudication due to in-stent restenosis of bare-metal stents in the right superficial femoral artery, and two Zilver PTXs were deployed. However, hemarthrosis developed, and aspirin and clopidogrel were discontinued. Thirty-six days later, she suddenly felt rest pain in her right leg. Angiography revealed total occlusion at the Zilver PTX implantation site, demonstrating late stent thrombosis. Aspiration and thrombolysis yielded adequate flow and symptom resolution. Follow-up catheterization was scheduled 6months later. While the Zilver PTX stents were angiographically patent, angioscopy demonstrated a large red thrombus and uncovered stent struts. Therefore, dual antiplatelet therapy was continued.

Extremely late drug-eluting stent thrombosis related to uncovered struts: the phantom menace

A 75-year-old man was referred to our institution for lateral ST-elevation myocardial infarction. He previously underwent a 2.5 × 18 mm sirolimus-eluting stent implantation on the first diagonal branch 9 years earlier for symptomatic stable coronary artery disease. He has been under aspirin for the past 8 years with an uneventful evolution. Thrombolysis, clopidogrel-loading …

Late and very late coronary stent thrombosis: Intravascular ultrasound findings and associations with antiplatelet therapy

Late and very-late stent occlusion remains a serious complication of coronary stenting. Despite their high anti-restenotic efficacy, drug-eluting stents (DES) have been associated to more late-thrombosis as compared to bare-metal stents (BMS). The aim of this study is to analyze the clinical presentation, angiographic, and intravascular ultrasound (IVUS) findings in patients with late or very late stent thrombosis and the relationship with the antiplatelet regimen. Between January 2007 and December 2011, 34 consecutive patients with clinical syndromes compatible with late or very-late stent occlusion were studied with IVUS during emergency catheterization; 25 had DES and 9 had BMS. Thrombotic total occlusion was more common in DES (16 = 64%) than BMS patients (2 = 22%; P = 0.02) and ST-segment elevation myocardial infarction was the predominant clinical presentation in the former group (60% compared to 22%; P = 0.05). The time elapsed between implantation and failure was much longer in DES patients: 33 ± 22 versus 17 ± 14 months for BMS; P = 0.05. IVUS analysis showed a higher incidence of incomplete stent apposition (ISA) in the DES group compared to the BMS group (56% vs. 11%; P = 0.005) and in-stent plaque rupture was the most common finding in the BMS group (78%). In DES group, ISA was found more frequently in patients still under dual antiplatelet therapy (71%). Very late DES failure often causes ST-elevation myocardial infarction; these very late events may not correlate with the interruption of antiplatelet therapy. Severe, late acquired ISA belongs to DES and is frequently observed in patients with very late DES thrombosis.

First Experience With Implantation of a Percutaneous Right Ventricular Impella Right Side Percutaneous Support Device as a Bridge to Recovery in Acute Right Ventricular Infarction Complicated by Cardiogenic Shock in the United States

We report the first implantation in the United States of a novel percutaneous right ventricular (RV) support device as a bridge to recovery in a patient with RV infarction with cardiogenic shock refractory to standard care. A 64-year-old man, with prior inferior wall myocardial infarction treated with percutaneous coronary intervention, presented with late drug-eluting stent thrombosis inferoposterior ST-segment–myocardial infarction complicated by cardiac arrest requiring defibrillation of ventricular tachycardia (Figure 1; Movie I and II in the online-only Data Supplement). Despite revascularization, fluid administration to a central venous pressure of 20 mm Hg, dobutamine and vasopressin infusions, and intra-aortic balloon pump counterpulsation, he remained in RV shock (cardiac index of 1.8 L/min per m2). With use of antiplatelet drugs, surgical cannulation for extracorporeal support was deemed an excessive risk. Figure 1. Acute inferoapical ST-elevation–myocardial infarction (STEMI) treated …