Predictors Of Early Stent Thrombosis Research Articles

High platelet reactivity strongly predicts early stent thrombosis in patients with drug-eluting stent implantation

Stent thrombosis (ST) is a fatal complication after percutaneous coronary intervention (PCI). The association between P2Y12 reaction unit (PRU) level and stent thrombosis occurrence remains unclear. Based on the multicenter, observational PTRG-DES (Platelet function and genoType-Related long-term proGnosis in DES-treated patients) registry of patients with drug-eluting stents (DES) implantation, a total of 11,714 patients with PRU values were analyzed. We sought to identify the predictors of early stent thrombosis (EST) and compared the primary outcome, a composite of cardiac death, myocardial infarction, and revascularization, between EST and non-EST groups. EST, defined as definite ST within 1 month after index PCI, occurred in 51 patients. PRU values were significantly higher in the EST group (263.5 ± 70.8 vs. 217.5 ± 78.7, p < 0.001). In multivariable analysis, PRU ≥ 252 (OR, 5.10; 95% CI 1.58–16.46; p = 0.006) and aspirin reaction unit ≥ 414 (OR 4.85; 95% CI 1.07–21.97; p = 0.040) were independent predictors of EST. The cumulative incidence of primary composite outcome at one year was significantly higher in the EST group (38.2% vs. 3.9%, Log-rank p < 0.001). In patients treated with clopidogrel after successful DES implantation, EST was associated with higher platelet reactivities, and a greater risk of cardiovascular events.Trial Registration: clinicaltrials.gov Identifier: NCT04734028.

Association between high platelet reactivity and early stent thrombosis in patients with drug-eluting stent implantation

Abstract Background Stent thrombosis (ST) is a potentially fatal complication after percutaneous coronary intervention (PCI). The association between P2Y12 reaction unit (PRU) level and stent thrombosis occurrence is not fully elucidated. Methods Based on the multicenter, observational PTRG-DES (Platelet function and genoType-Related long-term proGnosis in DES-treated patients) registry of patients with drug-eluting stents (DES) implantation, a total of 11,714 patients with PRU values were identified. The independent predictors of early stent thrombosis (EST) were assessed. The primary outcome after EST was the composite of cardiac death, myocardial infarction and any revascularisation. Key secondary outcomes were all-cause death, cardiac death, myocardial infarction, and any revascularisation. Results EST, defined as definite ST in less than 1 month after index PCI, was identified in a total of 51 patients. The PRU value was significantly higher in the EST group (263.5 ± 70.8 vs. 217.5 ± 78.7, p&amp;lt;0.001). In multivariable analysis, having a PRU value of ≥252 (OR, 5.10; 95% CI, 1.58-16.46; p=0.006) and an ARU value of ≥414 (OR 4.85; 95% CI, 1.07-21.97; p=0.040) were significant predictors of EST. The use of first-generation DES (OR 3.56; 95% CI, 0.98-12.99; p=0.054) also posed a higher risk for EST occurrence with a borderline significance. Cumulative incidence of the primary composite outcome was significantly higher in patients with EST (HR 18.7; 95% CI 12.8-27.3; p&amp;lt;0.001). Conclusion In patients treated with clopidogrel after successful DES implantation, EST was associated with higher PRU values, and a greater rate of adverse outcomes, including all-cause death and MI.

TCT-483 Predictors of Early Stent Thrombosis After Implantation of Drug-Eluting Stents in Daily Clinical Practice - A Subanalysis of the Large, Prospective DESIRE (Drug-Eluting Stent In the REal World) Registry

TCT-483 Predictors of Early Stent Thrombosis After Implantation of Drug-Eluting Stents in Daily Clinical Practice - A Subanalysis of the Large, Prospective DESIRE (Drug-Eluting Stent In the REal World) Registry

Clinical, angiographic, and intravascular ultrasound predictors of early stent thrombosis in patients with acute myocardial infarction

Risk factors reported for early stent thrombosis (EST) included acute coronary syndrome, suboptimal antiplatelet therapy, procedural factors such as residual dissection and underexpansion of stents, and smaller final lumen area and inflow/outflow disease (residual stenosis or dissection) by intravascular ultrasound (IVUS) [1–4]. However, the predictors of EST including all variables such as baseline characteristics, laboratory data, angiographic and IVUS findings in patients with acute myocardial infarction (AMI) are still not well known. From January 2007 to December 2009, we identified 418 consecutive patients with a first AMI who underwent pre-percutaneous coronary intervention (PCI) IVUS within 24 h from symptom onset, were stented successfully, and had post-PCI IVUS imaging. EST included acute (b24 h) and subacute ST (1 to 30 days) after stent implantation. Cardiac-specific troponin I (cTnI) levels were measured by a paramagnetic particle, chemiluminescent immunoenzymatic assay (Beckman, Coulter Inc., Fullerton, California). No-reflow was defined as postPCI TIMI grade 0, 1, or 2 flow. Tissue prolapse was defined as tissue extrusion through the stent strut at post-PCI. The baseline characteristics, angiographic and IVUS findings are summarized in Table 1. EST occurred in 16 patients (3.8%). Glycoprotein IIb/IIIa inhibitor was used more frequently in patients with EST compared with those without EST. Pre-PCI peak creatine kinase-MB and cTnI were significantly higher in patients with EST compared with those without EST. Pre-PCI TIMI flow grade was significantly lower in patients with EST compared with those without EST. More stents were deployed in patients with EST compared with those without EST. Noreflow during or after PCI was developed more frequently in EST group than in non-EST group (87.5% vs. 12.2%, p b 0.001). Plaque burden at the minimum lumen site was significantly greater in patients with EST compared with those without EST. Pre-PCI plaque rupture and IVUSdetected thrombuswere observedmore frequently in patients with EST compared with those without EST. Post-stenting tissue prolapse was observed more frequently in patients with EST compared with those without EST (68.8% vs. 32.6%, p= 0.003). Independent predictors of EST are summarized in Table 2. Multivariate analysis showed that noreflow, pre-PCI peak cTnI, and tissue prolapse were the independent predictors of EST. No-reflow can occur easily in lesions with various kinds of vulnerable plaque including plaque rupture and thrombus and this no-reflow is associated with microvascular damage which is likely to slow the epicardial coronary blood flow and to stagnate blood flow which may accelerate local thrombus formation [5]. The mechanism underlying the association between pre-PCI peak cTnI level and EST is not clear, although cTnI is associated with high thrombus grade with promoted thrombus formation in patients with AMI, who already have heightened systemic and intracoronary platelet reactivity, thrombin generation, and inflammation. Tissue prolapse may represent a source for thrombus accumulation in an environment that already has a high potential for thrombogenesis. Impaired arterial healing and ST have been associated with the prolapse of the necrotic core between stent struts. This is especially relevant in the setting of AMI, because such patients already have an increased risk for this devastating event [6]. In conclusion, the incidence of EST after stenting of infarct-related arteries was 3.8%. No-reflow, pre-PCI peak cTnI and tissue prolapse were associated with the development of EST after stent implantation in patients with AMI.

Clinical, Angiographic, and Intravascular Ultrasound Predictors of Early Stent Thrombosis in Patients with Acute Myocardial Infarction

Clinical, Angiographic, and Intravascular Ultrasound Predictors of Early Stent Thrombosis in Patients with Acute Myocardial Infarction

Intravascular Ultrasound Findings of Early Stent Thrombosis After Primary Percutaneous Intervention in Acute Myocardial Infarction

Background— Small stent area and residual inflow/outflow disease have been reported as the strongest intravascular ultrasound (IVUS) predictors of early stent thrombosis (ST) in patients with stable angina. IVUS predictors of early ST in patients with acute myocardial infarction have not been studied. Methods and Results— In the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) study, a formal substudy included poststent and 13-month follow-up IVUS at 36 centers. Twelve patients with baseline IVUS who had definite/probable early ST ≤30 days after enrollment were compared with 389 patients without early ST. Significant residual stenosis was a lumen area &lt;4.0 mm 2 with ≥70% plaque burden ≤10 mm from each stent edge. Significant edge dissection was more than medial dissection with lumen area &lt;4 mm 2 or dissection angle ≥60°. Randomization to bivalirudin ( P =0.29) or paclitaxel-eluting stent ( P =0.74) was not related to early ST. Minimum lumen area was smaller in patients with versus without early ST (4.4 mm 2 [3.6, 6.9] versus 6.7 mm 2 [5.3, 8.0], respectively, P =0.014). Minimum lumen area &lt;5 mm 2 , significant residual stenosis, significant stent edge dissection, and significant tissue (plaque/thrombus) protrusion (more than the median that narrowed the lumen to &lt;4 mm 2 ) were more prevalent in patients with early ST, but significant acute malapposition (more than the median) was not. Overall, 100% of patients with early ST had at least 1 of these significant features: minimum lumen area &lt;5 mm 2 , edge dissection, residual stenosis, or tissue protrusion versus 23% in patients without early ST ( P &lt;0.01). Conclusions— Smaller final lumen area and inflow/outflow disease (residual stenosis or dissection) but not acute malapposition were related to early ST after acute myocardial infarction intervention. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00433966.

The incidence and clinical predictors of early stent thrombosis in patients with acute coronary syndrome

Acute coronary syndrome (ACS) is associated with activation of platelets and the coagulation system which could influence the incidence of early stent thrombosis (EST). We aimed to determine the incidence and predictors of EST in patients undergoing coronary stenting during ACS. The study comprised 1202 consecutive patients, drawn from a nationwide ACS survey, who underwent coronary stenting during ACS and were followed up for 30 days. Early stent thrombosis was based on the Academic Research Consortium definition. Thirty patients (2.5%) sustained EST. The occurrence of EST in patients with unstable angina/non-ST-elevation myocardial infarction and ST-elevation myocardial infarction (STEMI) was 0.9% and 3.9%, respectively (P < .05), and was even higher (5.2%) in STEMI patients who underwent primary percutaneous coronary intervention. On multivariate analysis, STEMI (OR 6.3, 95% CI 2.1-18, P = .0008), multivessel disease (OR 5.9, 95% CI 1.9-21, P = .003) and Killip class >/=2 (OR 2.9, 95% CI 1.3-6.6, P = .008) were independent correlates of EST. The use of bare versus drug-eluting stents was not associated with any significant difference in EST. Patients presenting with STEMI who are hemodynamically unstable and have multivessel coronary disease undergoing coronary stenting during ACS, are at increased risk of EST.

Baseline platelet size is increased in patients with acute coronary syndromes developing early stent thrombosis and predicts future residual platelet reactivity. A case-control study

Introduction Pre-procedural predictors of early stent thrombosis (ST) and future response to platelet inhibitors are in demand. We sought to evaluate the impact of baseline platelet indices on the occurrence of early ST and future residual platelet reactivity. Materials and methods Hundred and eight patients with acute coronary syndromes (ACS) in whom stents were implanted were included: 36 consecutive ST cases and 72 matched controls. Platelet indices assessed with flow cytometry before stent implantation were retrieved from the department's data base. Residual platelet reactivity specific to aspirin (aspirin reaction units–ARU) and clopidogrel (P2Y12 reaction units–PRU) was assessed prospectively with VerifyNow ® under dual antiplatelet treatment. Results Platelet size reported as mean platelet volume (MPV) or proportion of large platelets (LPLT) was significantly higher in ST cases compared with controls (10.4, 95% confidence intervals [CI], 10.1-10.8 vs. 9.7, CI, 9.5-9.9, P = 0.0004 and 35.8, CI, 34.2-37.3 vs. 33.3, CI, 32.2-34.3, P = 0.007, respectively). Dual aspirin and clopidogrel poor-responsiveness was diagnosed significantly more often in ST cases than in controls (19.6% vs. 1.4%, P = 0.004), whereas no difference was observed for single aspirin or clopidogrel poor-responsiveness. A strong correlation was found between MPV and both, ARU ( r = 0.66, P < 0.0001) and PRU ( r = 0.55, P < 0.0001). Similarly, higher LPLT was associated with higher ARU ( r = 0.47, P < 0.0001) and PRU ( r = 0.38, P = 0.0001). Conclusions Baseline platelet size is increased in patients with ACS developing early ST and correlates with future residual platelet reactivity under aspirin and clopidogrel therapy. Dual but not isolated aspirin or clopidogrel poor-responsiveness appears to be associated with early ST.

Technique, Complication, and Long-Term Outcome for Endovascular Treatment of Iliac Artery Occlusion

The aim of this study was to report technical details, procedure-related complications, and results of endovascular treatment in chronic iliac artery occlusion. Between 2001 and 2008, endovascular treatments of 127 chronic iliac artery occlusions in 118 patients (8 women and 110 men; mean age, 59 years) were retrospectively reviewed. The study was based on Ad Hoc Committee on Reporting Standards (Society for Vascular Surgery/International Society for Cardiovascular Surgery Standards). All occlusions were treated with stent placement with or without preliminary balloon angioplasty. Kaplan-Meier estimators were used to determine patency rates. Univariate and multivariate analyses were performed to determine variables affecting successful recanalization, major complications, early stent thrombosis (<or=30 days), and primary and secondary patency rates. Initial technical success was achieved in 117 (92%) procedures. Successful recanalization was obtained by antegrade approach in 69 of 77 (90%) procedures and by retrograde approach in 52 of 105 (50%) procedures (p < 0.001). Complications were encountered in 28 (24%) patients [minor in 7 patients (6%) and major in 22 patients (19%)]. One death occurred in the operative period secondary to iliac artery rupture. Early stent thrombosis was seen in eight (7%) patients. Presence of critical limb ischemia (p = 0.03), subintimal recanalization (p = 0.03), and major complication (p = 0.02) were the independent predictors of early stent thrombosis on multivariate analysis. Primary and secondary patency rates at 5 years were 63 and 93%, respectively. Presence of critical limb ischemia, TASC type C iliac lesions, combined occlusions of both common and external iliac arteries, and major complications were associated with decreased patency rates on univariate analysis, whereas these factors were not independent predictors of stent patency on multivariate analysis. In conclusion, endovascular treatment of iliac artery occlusion has a high technical success rate with favorable long-term patency rate. Success of recanalization increases with use of the antegrade approach and with the presence of a stump of artery before the occlusion.

Abstract 2564: Predictors of Early Stent Thrombosis in Patients with Acute Coronary Syndromes in the Drug-Eluting Stent Era: Analysis from the ACUITY trial

Objectives. The purpose of this study was to evaluate the incidence and predictors of early (&lt;30days) stent thrombosis (ST) in pts with acute coronary syndromes (ACS) in the drug-eluting stent (DES) era. Background. Predictors of ST, including detailed quantitative coronary angiographic (QCA) analysis parameters have not been carefully investigated in pts with ACS. Methods. In the prospective, multicenter ACUITY trial, a total of 7,179 pts with moderate and high risk ACS were treated with stents (66.4% of whom received at least 1 DES). Among these pts, core lab QCA was performed in 3,518 (49.0%) pts. Results. Within 30 days, 101 pts (1.4%) suffered definite or probable ST by the Academic Research Consortium (ARC) definition. Pts with ST were older and had a higher prevalence of diabetes mellitus, prior MI and renal insufficiency, higher TIMI risk scores and ST segment deviation compared to those without ST. By core lab QCA pts with ST were more likely to have greater overall coronary artery disease burden, procedural angiographic complications, suboptimal final angiographic results, implantation of ≥2 stents, and use of aspirin &lt;50% of time within 30 days. A final stent diameter stenosis &gt;20% and implantation of ≥2 stents were the strongest independent predictors of early ST (Table ). DES use was not significantly different between pts with and without ST (62.4% vs. 66.5%, P=0.40). Conclusions. Early ST in pts with ACS is frequent with both BMS and DES, and is predicted by use of multiple stents and suboptimal angiographic results. Avoiding multiple stents and improving operator technique and antiplatelet compliance may minimize the risk of early ST in ACS. Multivariate predictors of early ST

Abstract 3343: Incidence and Predictor of Late Stent Thrombosis After Implantation of Sirolimus-eluting Stent: From Two-year Clinical Follow-up of The j-Cypher Registry

Background: Unsolved issue about Sirolimus-eluting stent is thrombosis, especially, the potential for late stent thrombosis (ST). Methods: To clarify the incidence and predictors of ST, two-year data of the j-Cypher Registry were examined using ARC definition. Design of this registry was multi-center prospective enrollment of 15,216 consecutive patients (pts) with anti-platelet regimen of aspirin and ticlopidine in Japan. Results: Pts’ characteristics of this cohort were as follows, age 68+/−10 years, male in 75%, diabetes in 42%, emergency procedure in 6.6%, hemodialysis in 5%, CKD ( CCr&lt;60, non-Hemodialysis ) in 51% and off-label use in 77%. Bifurcation lesion was observed in 19%. The other characteristics of lesions were as follows, in-stent restenosis in 12%, CTO in 9%, STEMI culprit in 6.3%. Cumulative ST (ARC definite/probable) rates within two-year were 0.62% at six-month, 0.71% at one-year and 0.93% at two-year as shown in the table . Annual increase slope of late ST (ARC definite) was 0.25% per year. During follow-up, 439 Surgical operations excluding endovascular and CABG were needed. Within 30 days of operation, clinical event rates were death in 2.2%, MI in 0.65% and ST in 0.44%. Multivariate analysis identified 3 independent predictors of early ST (within three-month); Hemodialysis: Odds Ratio (OR) = 1.75 (95%CI 1.02–2.69) p=0.042, Male gender: OR = 2.00 (1.20–4.08) p=0.0051, and Emergency procedure: OR = 2.15 (1.36–3.22) p= 0.0017. Also, multivariate analysis identified one independent predictor of late ST (beyond three-month); Hemodialysis: OR = 2.44 (1.29–4.14) p=0.042. Conclusions : Stent thrombosis rate up to two years under Ticlopidine anti-platelet regimen in Japan seemed to be lower as compared with those reported from other registries in the real world, despite the fact that high risk pts were more prevalent in the j-Cypher registry. Hemodialysis was identified to be independent predictor of early and late stent thrombosis through two years. Cumulative stent thrombosis rates in j-Cypher registry