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Very late thrombosis of a drug-eluting stent after discontinuation of dual antiplatelet therapy in a patient treated with both drug-eluting and bare-metal stents.
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PMID:  19949580     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
Drug-eluting stents (DESs) are the treatment of choice for obstructive coronary artery disease when percutaneous intervention is feasible. However, late stent thrombosis seems to occur more frequently with DESs and is closely associated with the discontinuation of dual antiplatelet therapy. We report a case of very late stent thrombosis after discontinuation of dual antiplatelet therapy. The patient suffered from acute myocardial infarction (MI) and underwent bare metal stent (BMS) implantation in the left anterior descending artery (LAD) five years prior to presentation. Three years after BMS implantation, he presented again with acute MI and had a DES implanted in the right coronary artery (RCA). He ran out of his medication, but failed to refill his prescription. Sixteen days after discontinuing medication, he experienced an episode of chest pain and was taken to the cardiac catheterization laboratory, where he was found to have thrombosis in the DES, but no thrombosis in the BMS. It is possible that DESs are more vulnerable to late thrombosis than are BMSs, supporting the use of prolonged dual antiplatelet therapy in patients treated with DESs. The patient was successfully treated with balloon angioplasty and thrombus aspiration without complications.
Authors:
Sung Soo Kim; Myung Ho Jeong; Doo Sun Sim; Young Joon Hong; Ju Han Kim; Young Keun Ahn; Jung Chaee Kang
Publication Detail:
Type:  Journal Article     Date:  2009-05-28
Journal Detail:
Title:  Korean circulation journal     Volume:  39     ISSN:  1738-5555     ISO Abbreviation:  Korean Circ J     Publication Date:  2009 May 
Date Detail:
Created Date:  2009-12-01     Completed Date:  2011-07-14     Revised Date:  2013-05-23    
Medline Journal Info:
Nlm Unique ID:  101247141     Medline TA:  Korean Circ J     Country:  Korea (South)    
Other Details:
Languages:  eng     Pagination:  205-8     Citation Subset:  -    
Affiliation:
The Heart Center of Chonnam National University Hospital, Gwangju, Korea.
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Journal Information
Journal ID (nlm-ta): Korean Circ J
Journal ID (publisher-id): KCJ
ISSN: 1738-5520
ISSN: 1738-5555
Publisher: The Korean Society of Cardiology
Article Information
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Copyright ? 2009 The Korean Society of Cardiology
open-access:
Received Day: 24 Month: 5 Year: 2008
Revision Received Day: 13 Month: 8 Year: 2008
Accepted Day: 18 Month: 9 Year: 2008
Print publication date: Month: 5 Year: 2009
Electronic publication date: Day: 28 Month: 5 Year: 2009
Volume: 39 Issue: 5
First Page: 205 Last Page: 208
ID: 2771789
PubMed Id: 19949580
DOI: 10.4070/kcj.2009.39.5.205

Very Late Thrombosis of a Drug-Eluting Stent After Discontinuation of Dual Antiplatelet Therapy in a Patient Treated With Both Drug-Eluting and Bare-Metal Stents
Sung Soo Kim, MD1
Myung Ho Jeong, MD12
Doo Sun Sim, MD12
Young Joon Hong, MD12
Ju Han Kim, MD12
Young Keun Ahn, MD12
Jung Chaee Kang, MD12
1The Heart Center of Chonnam National University Hospital, Gwangju, Korea.
2Cardiovascular Research Institute of Chonnam National University, Gwangju, Korea.
Correspondence: Correspondence: Myung Ho Jeong, MD, The Heart Center of Chonnam National University Hospital, 8 Hak-dong, Dong-gu, Gwangju 501-757, Korea. Tel: 82-62-220-6243, Fax: 82-62-228-7174, myungho@chollian.net

Introduction

In recent years, drug-eluting stents (DESs) have been shown to dramatically reduce the rate of restenosis and the need for repeat revascularization.1-3) Despite these promising results, late stent thrombosis seems to occur more frequently with DESs and seems to be closely associated with the discontinuation of dual aspirin/thienopyridine derivative (usually clopidogrel) antiplatelet therapy.1-4) We report a case of late DES thrombosis after discontinuation of dual antiplatelet therapy.


Case

A 49-year-old man was transferred to the emergency department complaining of squeezing chest pain that had increased in severity over the past four days. Five years prior to presentation, he had undergone percutaneous coronary intervention (PCI) for acute myocardial infarction (MI), along with implantation of a bare metal stent (BMS) (3.5?28 mm Arthos Inert Stent, AMG, Korea) in the left anterior descending artery (LAD) (Fig. 1). Six months later, he developed angina and underwent balloon angioplasty for in-stent restenosis (Fig. 2). Two years after that, he had a paclitaxel-eluting stent (2.75?32 mm Taxus Stent, Boston Scientific, USA) placed in the right coronary artery (RCA) after suffering another acute MI (Fig. 3). The patient was treated with dual antiplatelet therapy: aspirin (100 mg daily) and clopidogrel (75 mg daily). He ran out of his medication, but failed to refill his prescription. Sixteen days after discontinuing medication, he developed chest pain and presented to the emergency department. An electrocardiogram (ECG) performed at that time showed new ST-segment depression and T-wave inversion in leads II, III, and aVF (Fig. 4). Cardiac enzymes were also elevated (creatine kinase-MB 9.9 U/L, Troponin I 7.73 ng/mL, Troponin T 2.64 ng/mL). The patient underwent emergency coronary angiography, which revealed total occlusion of the DES in the proximal RCA due to very late stent thrombosis with grade II collateral flow (Fig. 5A and B). The BMS in the LAD was patent (Fig. 5C). After receiving an intravenous glycoprotein IIb/IIIa receptor blocker (abciximab), the patient underwent repeat balloon angioplasty and thrombus aspiration secondary to recurrent, immediate thrombus formation and coronary occlusion (Fig. 6A). The final angiogram showed good flow without residual stenosis (Fig. 6B).


Discussion

We report this case to draw attention to the phenomenon of very late stent thrombosis after DES implantation, which might be associated with serious clinical implications after the discontinuation of dual antiplatelet therapy. It is possible that DESs are associated with substantially higher rates of thrombosis when compared with BMSs.

Stent thrombosis (ST) is a generally fatal complication after PCI. It may occur in the acute (<1 day), subacute (<30 days), late (<1 year), or very late (>1 year) periods and may result in serious complications such as MI and death.5) Very late stent thrombosis (VLST) is defined as a stent thrombosis event that occurs beyond one year. The risk of VLST was analyzed using trial level data in a meta-analysis of 14 randomized trials in which 6,675 patients had been randomly assigned to PCI with DES or BMS.6) The incidences of VLST were 5.0 events per 1,000 patients in the DES group and 0 events per 1,000 patients in the BMS group (relative risk=5.0, 95% confidence interval 1.3-19.5). In another report, DESs were reported to have an approximately 0.3 to 0.5 percent greater risk of VLST compared with BMSs.7) Several factors were shown to be associated with ST, including older age, black race, diabetes mellitus, bifurcation lesion, instent restenosis lesion, post-procedure acute renal failure, and lack of clopidogrel therapy.8) Discontinuation of antiplatelet therapy, as an independent predictor of stent thrombosis, even several years after DES implantation, increases the risk of late stent thrombosis. This finding suggests that clopidogrel compliance may minimize the incidence of VLST after DES implantation.

Current recommendations suggest extending dual antiplatelet therapy beyond one year in patients with low bleeding risk. Antiplatelet treatment should be continued even if there is an increased risk of minor bleeding complications so that life-threatening complications, such as acute MI, are avoided. Patients with previously implanted DESs who are currently taking dual antiplatelet therapy are at high risk for developing stent thrombosis when a situation arises that requires cessation or interruption of dual platelet inhibition.9), 10)

The optimal duration of antiplatelet therapy in patients with coronary artery stents still remains to be determined. Further large-scale studies are needed to determine the optimal combination and duration of antiplatelet therapy that should be used to prevent these serious thrombotic events.


References
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2. Colombo A,Drzewiecki J,Banning A,et al. Randomized study to assess the effectiveness of slow- and moderate-release polymer-based paclitaxel-eluting stents for coronary artery lesionsCirculationYear: 200310878879412900339
3. Zhang F,Ge J,Qian J,et al. Sirolimus-eluting stents in real-world patients with ST-segment elevation acute myocardial infarctionInt Heart JYear: 20074830331117592195
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8. Kuchulakanti PK,Chu WW,Torguson R,et al. Correlates and long-term outcomes of angiographically proven stent thrombosis with sirolimus- and paclitaxel-eluting stentsCirculationYear: 20061131108111316490815
9. Park SH,Hong GR,Seo HS,Tahk SJ. Stent thrombosis after successful drug-eluting stent implantationKorean Circ JYear: 200535163171
10. Iakovou I,Schmidt T,Bonizzouni E,et al. Incidence, predictors, and outcome of thrombosis after successful implantation of drug eluting stentsJAMAYear: 20052932126213015870416
11. Flores-Rios X,Marzoa-Rivas R,Abugatt?s-de Torres JP,et al. Late thrombosis of paclitaxel-eluting stents: long-term incidence, clinical consequences, and risk factors in a cohort of 604 patientsAm Heart JYear: 200815564865318371471
12. Pfisterer M,Brunner-La Rocca HP,Buser PT,et al. Late clinical events after clopidogrel discontinuation may limit the benefit of drug-eluting stents: an observational study of drug-eluting versus bare-metal stentsJ Am Coll CardiolYear: 2006482584259117174201

Article Categories:
  • Case Report

Keywords: Thrombosis, Stents, Platelets.

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