Coronary stent thrombosis is nightmare and deathly

1. Coronary Stent Thrombosis
Nightmare for cardiologist

2. Let see how it looks!

3. 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.

4. Stent Paradox !
Cardiologist invites thrombus
Thrombus there
But not cardiologist
That’s a deathly nightmare

5. Tetrad of ST
Patient Stent Medication
Lesion Lesion Lesion

6. Definition of Stent Thrombosis According to
the Valve Academic Research Consortium
Level of certainty Time temporal
Definite
Angiographic or pathological confirmation of
partial or total thrombotic occlusion
within the peri-stent region
AND at least 1 of the following additional criteria:
Acute ischemic symptoms
Ischemic electrocardiogram changes
Elevated cardiac biomarkers
Early
Acute (<24 h)
Subacute (24 h
to 30 days
Probably
Any unexplained death <30 days of stent
implantation
Any myocardial infarction related to
documented acute ischemia in the
territory of the implanted stent
without angiographic confirmation of
stent thrombosis and in the absence
of any other obvious cause
Late
31 days to 1 yr
Possible
Any unexplained death beyond 30 days
Very late
More than 1 yr

7. ORACLE
Profile Early Late
Patient Malignancy, heart failure, peripheral artery disease, diabetes
mellitus,
acute coronary syndromes, nonadherence to dual-antiplatelet
therapy, genetic polymorphisms, thrombocytosis
End-stage renal disease, smoking, STEMI,
nonadherence
to dual-antiplatelet therapy (unknown for very
late 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
polymer
DES (compared with bioresorbable polymer
DES),
overlapping DES
Postprocedure Discontinuation of antiplatelet therapy Discontinuation of antiplatelet therapy
(unknown for
very late ST), late acquired stent
malapposition

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

9. 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

10. Who is culprit?
Cardiologist put stent, thrombus caused death

11. 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

12. 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

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

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

15. DAPT INTERRUPTION
Hurry
Should be postponed as long as
possible
 Aspirin should be continued.

No Hurry
• Postpone the procedure until 1
year after stent implantation
• Guideline recommended
period of 6 to 12 months

16. 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]