Characteristics of Earlier Versus Delayed Presentation of Very Late Drug‐Eluting Stent Thrombosis: An Optical Coherence Tomographic Study

Abstract

BackgroundThe pathophysiology underlying very late drug‐eluting stent (DES) thrombosis is not sufficiently understood. Using optical coherence tomography, we investigated characteristics of very late stent thrombosis (VLST) according to different onset times.Methods and ResultsA total of 98 patients from 10 South Korean hospitals who underwent optical coherence tomography for evaluation of very late DES thrombosis were retrospectively included in analyses. VLST occurred at a median of 55.1 months after DES implantation. All patients were divided into 2 equal groups of earlier versus delayed presentation of VLST, according to median onset time. In total, 27 patients were treated with next‐generation DES and 71 with first‐generation DES. Based on optical coherence tomography findings at thrombotic sites, main VLST mechanisms were as follows, in descending order: neoatherosclerosis (34.7%), stent malapposition (33.7%), and uncovered struts without stent malapposition or evagination (24.5%). Compared with patients with earlier VLST, patients with delayed VLST had lower frequency of uncovered struts without stent malapposition or evagination (34.7% versus 14.3%, respectively; P=0.019). Conversely, the frequency of neoatherosclerosis was higher in patients with delayed versus earlier VLST (44.9% versus 24.5%, respectively; P=0.034). The frequency of stent malapposition was not different between patients with earlier and delayed VLST (34.7% versus 32.7%, respectively; P=0.831). The frequency of stent malapposition, evagination, and uncovered struts was still half of delayed VLST.ConclusionsThe pathological mechanisms of very late DES thrombosis changed over time. Delayed neointimal healing remained a substantial substrate for VLST, even long after DES implantation.

Formation and Transformation of Neointima after Drug-eluting Stent Implantation: Insights from Optical Coherence Tomographic Studies

“… 21) 25) 26) 27) Neoatherosclerosis causes one-third of very late stent thrombosis cases. 25) 26) 27) Notably, the timing of very late stent thrombosis from in-stent plaque rupture is substantially earlier in first-generation DESs than BMSs. 22) Neoatherosclerosis has also been identified in both BMS and DES restenoses.…”

A scoring system to predict the occurrence of very late stent thrombosis following percutaneous coronary intervention for acute coronary syndrome

“…The representativeantiproliferation-drug-eluting stents of the first-generation drug-eluting stents (DESs) are SESs; local toxicity and inflammatory reactions after implantation of these stents could lead to delayed endothelialisation or even positive remodelling of the vessel walls. This is also an important mechanism involved in the development of VLST 16,[26][27][28][29][30] . Figure 2.…”

Impact of Diabetes Mellitus on the Early-Phase Arterial Healing After Drug-Eluting Stent Implantation

“…However, delayed arterial healing sometimes occurs after DES implantation due to the component of DES instead of preventing SMC proliferation, which can lead to instent restenosis (16). A pathological study suggested that widely uncovered struts are a risk factor for stent thrombosis (17), and optical coherence tomography studies reported that uncoverage was one of the mechanisms of stent thrombosis (18)(19)(20). In the present study, the CAS evaluation demonstrated that the rate of the minimum NIC of grade 0 was signi cantly higher in the DM group compared to the non-DM group at 3-5 months after DES implantation, which suggests that arterial healing is more delayed in patients with DM compared to those without it.…”