'Very' Very Late Stent Thrombosis
'Very' Very Late Stent Thrombosis
A serious long-term complication of drug-eluting stent (DES) implantation is the occurrence of very late stent thrombosis (VLST) beyond 1 year after implantation. While VLST has been observed as late as 3 to 5 years following the initial procedure, it remains unknown whether DES thrombosis is a finite phenomenon that abates over time or is a risk that persists indefinitely. We identified a series of patients who presented with acute myocardial infarction (MI) due to "very" very late stent thrombosis (VVLST), defined as occurring more than 5 years after DES implantation. The study group consisted of 7 patients (6 men and 1 woman), ages 32 to 70 years, who had angiographically confirmed definite VVLST. Six patients were active smokers and 4 were diabetic. The interval between stent implantation and VVLST ranged from 5.6 to 7.1 years. The DES was sirolimus-eluting in 4 patients and paclitaxel-eluting in 3 patients. None of the patients were taking clopidogrel and only 2 patients were taking aspirin at the time of VVLST. Therefore, 5 of the 7 patients were not on any antiplatelet therapy prior to VVLST. The clinical presentation of VVLST was an acute MI in all patients, with ST-segment elevation in 6 of the 7 patients. Six patients were treated successfully by emergent repeat percutaneous coronary intervention and 1 patient who was postoperative from neurosurgery was managed medically. In conclusion, the risk of stent thrombosis persists even beyond 5 years after first-generation DES implantation. These sobering findings underscore the importance of long-term clinical vigilance in these patients and reinforce current PCI guidelines, which recommend continuing at least aspirin indefinitely after DES.
Stent thrombosis (ST) remains a serious complication of percutaneous coronary intervention (PCI) resulting in myocardial infarction (MI) or death in up to 80% of patients. Compared to bare-metal stent (BMS) implantation, drug-eluting stents (DESs) are more prone to develop ST late after their implantation. Stent thrombosis occurring more than 1 year after PCI is classified as very late stent thrombosis (VLST) according to the definitions of the Academic Research Consortium (ARC). Most reported series of VLST have focused on events during the first 3 postprocedural years, with a few studies extended out to 5 years of follow-up. It remains unknown whether the risk of DES thrombosis eventually abates over time or persists indefinitely. In this report, we describe a series of patients with acute MI due to DES thrombosis occurring beyond 5 years after initial stent implantation. To our knowledge, this is the first reported series of patients who sustained ST after such an extended (>5 years) postprocedural interval, or what may be characterized as "very" very late stent thrombosis (VVLST).
Abstract and Introduction
Abstract
A serious long-term complication of drug-eluting stent (DES) implantation is the occurrence of very late stent thrombosis (VLST) beyond 1 year after implantation. While VLST has been observed as late as 3 to 5 years following the initial procedure, it remains unknown whether DES thrombosis is a finite phenomenon that abates over time or is a risk that persists indefinitely. We identified a series of patients who presented with acute myocardial infarction (MI) due to "very" very late stent thrombosis (VVLST), defined as occurring more than 5 years after DES implantation. The study group consisted of 7 patients (6 men and 1 woman), ages 32 to 70 years, who had angiographically confirmed definite VVLST. Six patients were active smokers and 4 were diabetic. The interval between stent implantation and VVLST ranged from 5.6 to 7.1 years. The DES was sirolimus-eluting in 4 patients and paclitaxel-eluting in 3 patients. None of the patients were taking clopidogrel and only 2 patients were taking aspirin at the time of VVLST. Therefore, 5 of the 7 patients were not on any antiplatelet therapy prior to VVLST. The clinical presentation of VVLST was an acute MI in all patients, with ST-segment elevation in 6 of the 7 patients. Six patients were treated successfully by emergent repeat percutaneous coronary intervention and 1 patient who was postoperative from neurosurgery was managed medically. In conclusion, the risk of stent thrombosis persists even beyond 5 years after first-generation DES implantation. These sobering findings underscore the importance of long-term clinical vigilance in these patients and reinforce current PCI guidelines, which recommend continuing at least aspirin indefinitely after DES.
Introduction
Stent thrombosis (ST) remains a serious complication of percutaneous coronary intervention (PCI) resulting in myocardial infarction (MI) or death in up to 80% of patients. Compared to bare-metal stent (BMS) implantation, drug-eluting stents (DESs) are more prone to develop ST late after their implantation. Stent thrombosis occurring more than 1 year after PCI is classified as very late stent thrombosis (VLST) according to the definitions of the Academic Research Consortium (ARC). Most reported series of VLST have focused on events during the first 3 postprocedural years, with a few studies extended out to 5 years of follow-up. It remains unknown whether the risk of DES thrombosis eventually abates over time or persists indefinitely. In this report, we describe a series of patients with acute MI due to DES thrombosis occurring beyond 5 years after initial stent implantation. To our knowledge, this is the first reported series of patients who sustained ST after such an extended (>5 years) postprocedural interval, or what may be characterized as "very" very late stent thrombosis (VVLST).
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