Fixed and Modifiable Correlates of Drug-Eluting Stent Thrombosis From a Large All-Comers Registry

Abstract

S tent thrombosis (ST) is an uncommon but catastrophic complication following stent implantation associated with a high incidence of myocardial infarction (MI) and death. [1][2][3] Drug-eluting stents (DES) have reduced restenosis and target vessel revascularization compared with bare metal stents, but less complete strut coverage and delayed healing may predispose to increased ST with these devices. 4,5 The correlates and consequences of ST after stent implantation have been evaluated in patient populations treated with bare metal stents and early-generation DES, 1,5-10 but there are limited studies from a more contemporary all-comers patient population, including the use of newer generation DES. 11The Assessment of Dual Anti-Platelet Therapy With DrugEluting Stents (ADAPT-DES) study is the largest prospective investigation to date evaluating the correlates and consequences of ST in patients treated with DES in an all-comers population.12 The study included a large proportion of patients treated with new-generation DES, evaluated routine testing of platelet reactivity after aspirin and clopidogrel loading, and assessed the role of intravascular ultrasound (IVUS) guidance Background-Previous studies evaluating correlates of stent thrombosis (ST) have included mostly patients with bare metal stents and early-generation drug-eluting stents (DES) and have not systematically evaluated the role of intravascular ultrasound-guided stenting and high platelet reactivity on clopidogrel. The purpose of this study was to evaluate the frequency and correlates of ST in patients receiving DES, specifically examining the impact of risk factors modifiable by physician and patient behavior. Methods and Results-Assessment of Dual Anti-platelet Therapy With Drug-Eluting Stents (ADAPT-DES) was a multicenter, prospective study in patients undergoing successful coronary intervention with DES in whom routine platelet reactivity testing was performed.

Impact of lesion complexity on peri-procedural adverse events and the benefit of potent intravenous platelet adenosine diphosphate receptor inhibition after percutaneous coronary intervention: core laboratory analysis from 10 854 patients from the CHAMPION PHOENIX trial

“…Major adverse cardiac event rates in CHAMPION PHOENIX were higher after PCI in SIHD compared with ACS due to greater rates of peri-procedural MI in SIHD, a finding explainable by challenges in adjudicating PCI-induced myonecrosis in ACS patients in whom baseline biomarker levels are already elevated. 15 However, stent thrombosis rates were greater in patients with ACS (as expected), 16 , 17 and steadily increased with the number of PCI target lesion HRFs. The absolute reduction in the 48-h rate of stent thrombosis following treatment with cangrelor compared with clopidogrel was particularly notable after PCI of lesions with ≥3 HRFs [1.0% vs. 2.3%, OR (95% CI) 0.43 (0.23, 0.82)], with 1.6% and 1.1% absolute stent thrombosis reductions in ACS and SIHD respectively.…”

Angiographic predictors of 2‐year stent thrombosis in patients receiving drug‐eluting stents: Insights from the ADAPT‐DES study

“…Hence, in terms of the interaction between HPR and lesion complexity their results diverge from ours; however, HPR trended as an independent predictor in our analysis. Furthermore, an earlier report from ADAPT‐DES identified HPR as an independent predictor of early but not late ST . Therefore, patients with complex lesions and HPR may be at particularly high risk for ST.…”

Role of residual acute stent malapposition in percutaneous coronary interventions

“…Despite technological progress in terms of stent/polymer/drug platform and implantation technique, stent thrombosis (ST) remains a rare but important cause of acute and late stent failure . Albeit the pathogenic mechanism underlying ST is likely multifactorial, some publications suggested that acute stent malapposition (ASM) could play a role in determining ST, while others focused on the relationship between persistent stent malapposition, regardless of whether acute or late acquired, and very late ST .…”