Coronary Stent Thrombosis

Nightmare for cardiologist

Let see how it looks!

Get involved to prevent

Understanding• Serious complication of PCI.• DES=BMS for early and late ST• Frequently in first-generation DES• Risk factors-Modifiable(Most) • Address

• Patient• Lesion• Stent• DAPT

Prevention is better• a good technical result; and

effective DAPT• are critical in minimizing the risk

of ST.

Stent Paradox !

Cardiologist invites thrombus Thrombus there

But not cardiologist That’s a deathly nightmare

Tetrad of ST

MedicationStent Patient

Lesion Lesion Lesion

Definition of Stent Thrombosis According to the Valve Academic Research Consortium

Level of certainty Time temporal

DefiniteAngiographic or pathological confirmation ofpartial or total thrombotic occlusionwithin the peri-stent regionAND at least 1 of the following additional criteria: Acute ischemic symptomsIschemic electrocardiogram changesElevated cardiac biomarkers

Early

Acute (<24 h)Subacute (24 hto 30 days

ProbablyAny unexplained death <30 days of stentimplantationAny myocardial infarction related todocumented acute ischemia in theterritory of the implanted stentwithout angiographic confirmation ofstent thrombosis and in the absenceof any other obvious cause

Late31 days to 1 yr

PossibleAny unexplained death beyond 30 days

Very late

More than 1 yr

ORACLE

Profile Early Late

Patient Malignancy, heart failure, peripheral artery disease, diabetes mellitus,acute coronary syndromes, nonadherence to dual-antiplatelettherapy, genetic polymorphisms, thrombocytosis

End-stage renal disease, smoking, STEMI, nonadherenceto dual-antiplatelet therapy (unknown for verylate ST)

Lesion Bifurcation lesion, LAD, vessel size, lesion length, thrombus,saphenous vein grafts

LAD, incomplete endothelialization, delayed healing,previous brachytherapy, vein graft stenting

Procedure Stent undersizing, stent underexpansion, stent malapposition,dissection, no pre-procedural thienopyridine administration,bivalirudin as anticoagulant in STEMI patients, stent length

DES (compared with BMS), permanent polymerDES (compared with bioresorbable polymer DES),overlapping DES

Postprocedure Discontinuation of antiplatelet therapy Discontinuation of antiplatelet therapy (unknown forvery late ST), late acquired stent malapposition

INTRAVASCULAR IMAGING

• Expansion• Apposition• Stent fracture• Dissection• Malposition• Thrombus• Neo-atherosclerosis• New plaque rupture• Negative remodelling at the stent edge

Factors used for risk score

• NSTE MI• STEMI• Current smoking • Insulin-treated diabetes mellitus • History of PCI • Platelet count• Pre-PCI Heparin• Aneurysm or ulceration • TIMI flow grade (Base)• Final TIMI flow • No. of vessels treated

Who is culprit?

Cardiologist put stent, thrombus caused death

PLATO IS SOVERIGN AND TICA IS KING

RCT YEAR F/U Comparison Definite of probably ST p bleeding p

TRITON 2K7 15M CLOPI VS PASU 24.4/1.1 0.001 1.8 (111/6716)2.4 (146/6741) 0.03

PLATO 2K9 12M CLOPI VS TICA 2.9/2.2 0.009 7.7 (638/9186)7.9 (657/9235) .57

CHAMPION 2K9 48H CLOPI VS CANGRE 0.3/02 0.34 0.3 (14/4365)0.4 (19/4374) 0.39

CHAMPION FOENIX 2K9 48H CLOPI VS CANGRE 1.4/0.8 0.01 0.1 (5/5527)0.1 (5/5529) 0.99

CURRENT -OASIS 7 2K10 1M CLOPI VS 2XCLOPI 2.3/1.8 0.001 0.7 (60/8703)1.0 (80/8560) 0.074

Learning curve• From 2004 to 2014 ST related

death dropped from 50% to 1%• BMS changed to DES in 2005• 1ST generation banned • 2ND AND 3RD generation replaced

1st generation DES• ARC came in 2008

TECHNIQUE

• Newer generation stent(OK)• Expansion[No residue]• Apposition [full length]• Dissections[No residual-IVUS]• Provisional stenting[Preferred]• Crush and Culotte[Discourage]

DAPT compliance

• Do not stop at all• Never stop during 1st month• If stopped ,expect ST in 7 days

DAPT INTERRUPTION

HurryShould be postponed as long as

possible Aspirin should be continued.

No Hurry• Postpone the procedure until 1

year after stent implantation• Guideline recommendedperiod of 6 to 12 months

Subha Diwali 2014

• Light for ST is not enough what is given here,You have to light it for yourself from today[23-10-2014]