Very late drug-eluting stent thrombosis after nonsteroidal anti-inflammatory drug treatment despite dual antiplatelet therapy

Abstract

C oronary stent thrombosis is a rare (1) but life-threatening complication of coronary angioplasty that usually occurs within 30 days of stent implantation (acute or subacute stent thrombosis). Within the first 30 days, the frequency of stent thrombosis is similar after either bare metal stent or drug-eluting stent (DES) implantation, when dual antiplatelet therapy is maintained (1). Recently, concerns have emerged about the high risk of late stent thrombosis (more than 30 days) after DES implantation due to delayed coronary endothelization, late stent malapposition or aneurysm formation (2). Based on a meta-analysis of multicentre, randomized studies, the predicting factors of late stent thrombosis include stent length and the discontinuation or ineffectiveness of thienopyridine-based antiplatelet therapy (1).There are few reports on very late stent thrombosis (VLST) (occurring more than one year after implantation), likely because of the lack of late follow-up in randomized studies on coronary stents. We report a case of VLST that occurred more than two years after primary angioplasty with sirolimus-eluting stent implantation in a patient on concomitant nonsteroidal anti-inflammatory drug (NSAID) therapy. Case presentationOn February 15, 2004, a 39-year-old man with a 2.5 h inferior ST segment elevation myocardial infarction (STEMI) and a medical history of diabetes mellitus and hypertension was referred for primary percutaneous coronary intervention (PCI). Coronary angiography demonstrated total occlusion of the proximal right coronary artery (RCA) ( Figure 1A) and 70% stenosis of both the middle portion of the left anterior descending artery and the left circumflex artery. BaCKGroUnD: Drug-eluting coronary stent implantation emerged as a safe and effective therapeutic approach by preventing coronary restenosis and reducing the need for further revascularization. However, in contrast to bare metal stents, recent data suggest a unique underlying pathology, namely late coronary stent thrombosis and delayed endothelial healing. oBJeCtiVe: To report a case of very late coronary stent thrombosis (834 days after implantation) requiring repeat urgent target-vessel revascularization. Importantly, six days before the acute coronary event, combined nonsteroidal anti-inflammatory drug therapy was initiated. resULts: Although a dual antiplatelet regimen was continuously maintained, aggregation measurements indicated only partial antiplatelet effect, which returned to the expected range when nonsteroidal antiinflammatory drugs were omitted. ConCLUsions: The observation indicates that, even 834 days after drug-eluting stent implantation, effective combined antiplatelet therapy might be crucial in certain individuals and the possible impact of drug interactions should not be underestimated. Further efforts should focus on the challenging task of identifying patients or medical situations with prolonged, increased risk of stent thrombosis.

Aneurysmal and Perianeurysmal Changes After Endovascular Treatment: from Inflammation to Microbleed. A Case Report

“…It is imperative in these cases to control the inflammatory response, thereby justifying the administration of high-dose steroid therapy. Caution should be adopted in the combination of clopidogrel or aspirin with nonsteroidal anti-inflammatory drug, since the latter could weaken their antiaggregation effect, increasing the risk of in-stent thrombosis [10].…”

Magnetically Coated Bioabsorbable Stents for Renormalization of Arterial Vessel Walls after Stent Implantation

“…Use of these medications can result in unwanted side effects, and are rendered less than optimally effective due to patient non-compliance to the drug regimen. 3,4 For those reasons, drug eluting stents have raised hopes since they provision a drug locally to the affected region, minimizing side effects, and in a sustained manner, facilitating automatic patient compliance. 5 However, the main complication have been the long-term effects such as late thrombosis and delayed endothelialization which, collectively, may result in myocardial infarctions.…”

“…Conventional treatment for these complications entail the use of antimitotic agents coating the stent to prevent restenosis and antiplatelet medications such as Clopidogrel (Plavix), Prasugrel (Effient), Ticagrelor (Brilinta), and Ticlopidine (Ticlid) to prevent thrombosis. Use of these medications can result in unwanted side-effects, and are rendered less than optimally effective due to patient noncompliance to the drug regimen. , For those reasons, drug-eluting stents have raised hopes since they provision a drug locally to the affected region, minimizing side-effects, and in a sustained manner, facilitating automatic patient compliance . However, the main complications have been the long-term effects such as late thrombosis and delayed endothelialization which, collectively, may result in myocardial infarctions .…”