Late stent thrombosis in the absence of prior intracoronary brachytherapy

Abstract

Late stent thrombosis has not been reported in the absence of prior coronary brachytherapy. We reviewed our experience in 1,855 consecutive patients who received at least one stent and did not receive coronary brachytherapy. Half of all stent thromboses occurred within the first week and nearly 65% (22) occurred within 15 days. The incidence of stent thrombosis within this traditional time frame was 1.2%. An additional 12 patients, however, presented with stent thrombosis between 33 and 270 days post-procedure (mean ‫؍‬ 72.9 ؎ 23 days). The true incidence of stent thrombosis was therefore 1.8% (34/1,855). There were three bypass operations, one stroke and two deaths in the late stent thrombosis group. Late stent thrombosis is an unusual but serious complication in patients who have not received coronary brachytherapy. Intracoronary radiation may potentiate a phenomenon that already occurs after stent deployment. Prolonged treatment (6 -12 months) with anti-platelet agents should be considered after percutaneous intervention with coronary stents. Cathet Cardiovasc Intervent 2001;53:23-28.

A Case Report of Late Coronary Stent Thrombosis Manifested as Acute Myocardial Infarction 19 Months After Stenting

“…1,2) Although the in-stent thrombosis could not be directly confirmed with thrombectomy and was not directly observed by IVUS or angioscope, the angiographical radiolucency at the prior stent ( Figure 2B & C) strongly suggested that AMI was induced by stent thrombosis. Angiographic radiolucency in case of ACS is considered to be an athero-thrombus which is the genesis of ACS, and prior reports concerning LST 1,2) were also diagnosed as LST with an angiogram (radiolucency). Therefore, the lack of direct evidence of thrombotic intrastent occlusion is a limitation for the clinical diagnosis in these cases.…”

“…1,2) According to a small retrospective study, 2) LST was reported to occur in a similar proportion of patients (a few percent) as acute and subacute thrombotic occlusion after stenting, suggesting that LST is not rare and should be emphasized as an important late complication after stenting. Although the known causative factors of early stent thrombosis 4,5) and ISR in its chronic phase (about six months after implant) 6) were not relevant to this case ( Figure 1D), abrupt thrombotic occlusion at the prior stent could be triggered and induced by abnormal endothelialization on the stent strut: ie, lack of endothelialization, 7) residual red thrombus, 7) rupture (or dissection) of hyperplasic neointima due to persistent arterial inflammation at the stenting site.…”

“…This paper presents a case study of LST without prior brachytherapy manifested as acute myocardial infarction (AMI) 19 months after stenting, the longest interval among previous reports. 1,2) This case suggests that AMI might occur during long-term follow-up after stenting without an angiographic ISR or clinical symptoms, suggesting that the pathophysiological mechanism of and clinical treatment for LST need clarification.…”

“…[1][2][3] LST is a serious problem because not only does it occur abruptly as acute coronary syndrome (ACS) with associated high mortality, 1) but it also occurs even if angiographic in-stent restenosis (ISR) was not observed at the second study. However, in contrast to LST with prior brachytherapy, 3) LST without prior brachytherapy has not become more common despite the increased use of coronary stents in ischemic heart diseases.…”

The Canadian Association of Interventional Cardiology and the Canadian Cardiovascular Society joint statement on drug-eluting stents

“…Multiple studies have confirmed that stent thrombosis occurring at any time point following either bare metal stent (BMS) or DES implantation is a very serious adverse event associated with high rates of death and nonfatal myocardial infarction (3)(4)(5)(6)(7). During 2006, dissemination of the results of the Basel Stent Cost-effectiveness Trial -Late Thrombotic Events (BASKET-LATE) (8) and other DES trial metaanalyses (9,10) raised widespread concerns about an increase in late (more than 30 days) and very late (more than 12 months) stent thrombosis in patients treated with DES compared with those receiving BMS.…”