Early stent thrombosis confirmed in a cancer patient receiving regorafenib, despite triple antithrombotic therapy: a case report

Abstract

Background While developments in oncology have lengthened survival in patients with cancer, such patients often develop cardiovascular diseases. Thus, percutaneous coronary intervention (PCI) is frequently undertaken in them. Although stent thrombosis remains a fatal complication in stent-based PCI, worldwide consensus panels tend to recommend shorter duration of dual-antiplatelet therapy. This is based on its clinical efficacy that has resulted from technological innovation. However, there is insufficient discussion on the risk of stent thrombosis in cancer patients with coronary artery disease, especially in those undergoing chemotherapeutic regimens that have a risk for thrombosis, such as regimens with the anti-vascular endothelial growth factor. Presented here is a case of early stent thrombosis that occurred in a cancer patient on regorafenib, despite the administration of triple antithrombotic therapy. Case presentation A 66-year-old Japanese male patient received regorafenib for metastatic colorectal carcinoma and apixaban for deep vein thrombosis. Coronary angiography revealed severe stenosis in the proximal left anterior descending artery. A sirolimus-eluting stent was implanted, without malapposition and under-expansion, under intravascular ultrasound guidance while administering a triple antithrombotic therapy (aspirin: 100 mg/day, prasugrel: 3.75 mg/day, and apixaban: 5 mg/day). However, he was admitted to the hospital for exacerbation of heart failure 1 month after PCI. Coronary angiography revealed contrastive defects in the previous stent. Optical frequency domain imaging confirmed stent thrombosis. PCI was successfully performed with perfusion balloon long-inflation. Antithrombotic therapy was enhanced (aspirin: 100 mg/day, ticagrelor: 120 mg/day, and apixaban: 10 mg/day) and regorafenib was discontinued permanently. While ischemic events did not occur thereafter, the patient died due to metastatic carcinoma progression. Conclusions This case suggests that anti-vascular endothelial growth factor might contribute to early stent thrombosis, despite triple antithrombotic therapy. Further discussion is needed on the surveillance and management of cancer patients with coronary artery disease receiving chemotherapy, which carries a risk of thrombosis.

Patient-Related Factors Predicting Stent Thrombosis in Percutaneous Coronary Interventions

“…Notably, patients who experience ST demonstrate a diminished capacity for forming endothelial progenitor colonies [66]. In individuals with cancer, the levels of endothelial and circulating progenitor cells are often suppressed, particularly during the acute phase of treatment, and may remain lower in those receiving therapies targeting the vascular endothelial growth factor (VEGF) [67,68].…”

“…• Cytostatic and cytotoxic chemotherapeutic agents may hinder the process of stent endothelialization, secondary to a diminished capacity for forming endothelial progenitor colonies, particularly during the acute phase of treatment [66][67][68]; • Patients undergoing thoracic EBRT have an increased risk of developing ischemic heart disease, and the risk is closely correlated with the average radiation dose absorbed by the heart [69,70];…”