“Very” Very Late Stent Thrombosis

The field of interventional cardiology was born on the shoulders of Andreas Gruentzig, MD, who performed the first balloon angioplasty in 1977.  Despite the initial skepticism toward the procedure, balloon angioplasty became a commonplace treatment of coronary artery disease.  Due to unacceptably high rates of acute ischemic complications and restenosis, further innovation led to development of the Palmaz-Schatz balloon-expandable intracoronary stent, which gained FDA approval after the landmark STRESS and BENESTENT trials demonstrated a reduction in restenosis. Despite bare-metal stents (BMSs) being touted as a game changer, issues with restenosis and stent thrombosis (ST) remained despite advances in antiplatelet regimens and deployment techniques. In 2003, ten years after the approval of BMS implantation, drug-eluting stents (DESs) came to the market due to the significantly lower rates of restenosis compared with BMS. Just 6 months after their approval, the FDA issued an advisory to physicians reporting adverse events associated with the Cypher DES and over the next 4 years, numerous reports of late and very late DES thrombosis – not often seen with BMS – were being reported. This led to numerous guideline revisions regarding the recommended duration of antiplatelet therapy following DES placement.
As we have now passed the first decade of the FDA approval of DESs, in this month’s Journal of Invasive Cardiology, we report a series of patients who presented with acute myocardial infarction (MI) due to “very” very late stent thrombosis (VVLST) occurring more than 5 years after implantation of a first-generation DES. This is the largest reported series of patients with definite ST occurring this far out after DES implantation. Our case series highlights the importance of maintaining antiplatelet therapy in patients with prior DES implantation as only 2 patients were on aspirin and none were on dual-antiplatelet therapy at the time of the late event. Interestingly, 6 patients were active smokers at the time of ST. Our study emphasizes that physicians must be aware that the risk for VVLST does not abate over time with first-generation DESs and supports the ACCF/AHA/SCAI PCI guideline recommendation that “aspirin should be continued indefinitely.” It is unclear whether second-generation DESs will be prone to VVLST since they have only been available for just over 5 years. These sobering findings underscore the need for long-term clinical vigilance, continuation of antiplatelet therapy, and smoking cessation following coronary artery stenting.

Antony G. Kaliyadan, MD
David L. Fischman, MD
Michael P. Savage, MD
Division of Cardiology
Thomas Jefferson University Hospital
Philadelphia, PA

Read the entire article at:
Kaliyadan A, Siu H, Fischman DL, Ruggiero NJ, Jasti B, Walinksy P, Ogilby D, Savage MP. “Very” Very Late Stent Thrombosis: Acute Myocardial Infarction From Drug-Eluting Stent Thrombosis More Than 5 Years After Implantation. Journal of Invasive Cardiology. 2014;26[9]:413-416.

Find more articles about Very Late Stent Thrombosis at http://www.invasivecardiology.com:
Yahagi K, Joner M, Virmani R. Insights Into Very Late Stent Thrombosis From the Wisdom of Pathology. J Invasive Cardiol. 2014;26(9):417-419.

Karjalainen PP, Nammas W, Ylitalo A. Late stent thrombosis of a second-generation drug-eluting stent. J Invasive Cardiol. 2012 Oct;24(10):E225-E227.

García E, Serra A, Zueco JJ, et al. Long-term clinical performance of paclitaxel-eluting stents coated with a bioactive polymer (P-5) containing a triflusal derivative: results of the REWAC registry. J Invasive Cardiol. 2013 Aug;25(8):391-396.

Puri A, Saireddy R, McClean D. Simultaneous two-vessel very-late stent thrombosis of everolimus-eluting stents. J Invasive Cardiol. 2013 Mar;25(3):E48-50.

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