Stent thrombosis after primary percutaneous coronary intervention is relatively frequent and continues to increase out to 5 years. New strategies are needed to prevent ST in STEMI patients, and targeted therapies are needed in patients identified at highest risk.

The sphenomandibular ligament, which is derived from the sheath of Meckel's cartilage, is a fibrous structure that passes between the spine of the sphenoid bone and the lingula of the mandible. Although anatomical texts provide basic descriptions of this structure, there are few published reports of the extent of its variability or its possible clinical implications. The aim of this study was to provide a detailed description of the nature and extent of anatomical variability in the sphenomandibular ligament of seven human cadavers. Dissections of sagittally sectioned heads were performed using a medial approach that involved displacement of the tongue and mucosal tissues in the oral cavity and oropharynx, then reflection of the medial pterygoid muscle. The ligaments ranged in shape from thin bands that descended for a short distance from the spine of the sphenoid to broad bi-concave ligaments with prominent insertions. The mylohyoid nerve was seen to pass behind the ligament in all specimens, emerging from the postero-inferior border of the mandibular attachment before running into the mylohyoid groove on the medial surface of the ramus. Lying in the pterygomandibular space, the ligament was surrounded by fascia, both structures presenting potential barriers to the diffusion of local anaesthetic solution if injected medially. The appearance of the lingula also varied, and did not seem to reflect the size of attachment of the ligament, suggesting an alternative explanation of lingula morphology, perhaps related to a continuation of the mylohyoid ridge and anterior border of the mylohyoid groove.

Objectives: This study compares very late outcomes following primary percutaneous coronary intervention for ST-elevation myocardial infarction (STEMI) with stenting versus balloon angioplasty (BA). Background: Stenting compared with BA for STEMI improves outcomes at 6–12 months, but comparisons beyond 6–12 months have not been studied. Recent studies have shown that stent thrombosis (ST) continues to increase beyond 3–5 years and may be higher with drug-eluting stents (DES) than bare metal stents (BMS). We hypothesized that there may be a very late hazard with stenting versus BA due to very late ST. Methods: From 1994 to 2010 consecutive patients with STEMI treated with BA (n = 601) or stenting (n = 1,594) were prospectively enrolled in our registry and followed for 1–16 years. Results: Patients treated with BA were older, were more often female, had more three-vessel disease, and had smaller vessels. Stented patients had trends for less stent/lesion thrombosis (ST/LT) and target vessel (TV) reinfarction at 1 year. In landmark analyses >1 year, stented patients had more very late ST/LT (6.1% vs. 2.9%, P = 0.002) and more TV reinfarction (7.9% vs. 3.1%, P < 0.001) which remained significant after adjusting for baseline risk. The greatest differences in very late outcomes were between DES and BA, but there were also significant differences between BMS and BA. Conclusions: There appears to be a very late hazard with stenting versus BA for STEMI. These data should encourage new strategies for prevention of very late ST with both BMS and DES including the development of bioabsorbable polymers and stent platforms.

New generation DES in STEMI patients have less ST compared to BMS and trends for less ST compared to early generation DES. These data suggest a new safety paradigm and should encourage the use of new generation DES in most STEMI patients treated with primary percutaneous coronary intervention (PCI).

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