Gul, Ibrahim

Nabi, Amjad

Rahman, Muhammad Nasir

English

eCommons@AKU

eCommons@AKUSection of Cardiology Department of MedicineApril 2017Very Late Stent Thrombosis: Is There Any Limit,When to Stop Antiplatelet Therapy?Muhammad Nasir RahmanAga Khan University, nasir.rahman@aku.eduIbrahim GulAga Khan UniversityAmjad NabiAga Khan UniversityFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_med_cardiolPart of the Cardiology CommonsRecommended CitationRahman, M. N., Gul, I., Nabi, A. (2017). Very Late Stent Thrombosis: Is There Any Limit, When to Stop Antiplatelet Therapy?. Journalof the College of Physicians and Surgeons Pakistan, 27(4), 260.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_med_cardiol/95260 Journal of the College of Physicians and Surgeons Pakistan 2017, Vol. 27 (4): 260Sir,The advent of stent implantation has dramaticallychanged the management of coronary artery disease(CAD).1 However, this management modality broughtwith it, a number of issues like stent thrombosis (STh)and in-stent restenosis (ISR), apart from proceduralcomplications and financial burden. Although the issueof ISR was, to a great extent, resolved with theintroduction of drug eluting stents (DES), very late stentthrombosis (VLST) still occurs from time to time,especially with first generation DES, due to delayed andineffective endothelialization.2A 72-year patient with hypertension, diabetes mellitusand prior percutaneous implentaion (PCI) of left anteriordescending (LAD) artery with SES (CYPHER®) (3.0 x 28)more than eight and a half years ago, presented to ouremergency department with acute anterior wall STelevation myocardial infarction (STEMI). He was onsingle antiplatelet drug (Clopidogrel, 75 mg daily) whichtoo was stopped by his physician 4 days prior to thecurrent event, due to an episode of melena.His emergency coronary angiography showed totalocclusion of LAD with thrombus and mild plaquing in therest of coronary arteries (Figure 1).LAD thrombus was aspirated, followed by intravascularultrasound (IVUS) which showed advanced positiveremodeling, unapposed stent in proximal and midportion and moderate ISR at the distal edge of the stent(Figure 2). The proximal to mid portion of stent was post-dilated and a DES (Xience-V) (Abbott®) was deployedto cover the ISR at the distal edge (Figure 3). Post-stentdeployment, IVUS showed well apposed stent.Although, VLST is a rare phenomenon in the modern eraof advanced and sophisticated stent implantation tech-niques, equipment, dual antiplatelet drugs and reverseremodeling therapy, it does occur, more commonly inpatients who discontinue their antiplatelet therapy.3 It isrelatively common with first generation DES, especiallySES (CYPHER®) because of severe inflammatoryresponse in the form of eosinophils, lymphocytes andgiant cells, leading to significant positive remodeling andmalapposition.4 The same occurred in our case too.Thus, it is very important for health professionals to keepin mind, VLST in patients having SES. If it is necessaryto stop antiplatelet therapy due to some reason, physiciansshould vigilantly monitor such patients and should re-administer antiplatelet therapy as soon as possible.REFERENCES1. Sigwart U, Puel J, Mirkovitch V, Joffre F, Kappenberger L.Intravascular stents to prevent occlusion and re-stenosis aftertransluminal angioplasty. N Engl J Med 1987; 316:701-6.2. Kang SJ, Lee CW, Song H, Ahn JM, Kim WJ, Lee JY, et al.OCT analysis in patients with very late stent thrombosis. JACCCardiovasc Imaging 2013; 6:695-703.3. Daemen J, Wenaweser P, Tsuchida K, Abrecht L, Vaina S,Morger C, et al. Early and late coronary stent thrombosis ofsirolimus-eluting and paclitaxel-eluting stents in routine clinicalpractice: Data from a large two-institutional cohort study.Lancet 2007; 369:667-78.4. Nakazawa G, Finn AV, Vorpahl M, Ladich ER, Kolodgie FD,Virmani R. Coronary responses and differential mechanisms oflate stent thrombosis attributed to first-generation sirolimus-and paclitaxel-eluting stents. J Am Coll Cardiol 2011; 57:390-8.LETTER TO THE EDITORVery Late Stent Thrombosis:Is There Any Limit, When toStop Antiplatelet Therapy?Figure 1: Still image of coronary angiogramshowing total occlusion of proximal left anteriordescending (LAD) artery and mild plaquing in leftcircumflex (LCX) artery.Figure 3: Still image of coronary angiogram afterstent implantation showing patent left anteriordescending (LAD) artery.Figure 2: Still image of the intravascular ultra-sound of left anterior descending (LAD) arteryshowing unapposed stent and positive remodeling.Muhammad Nasir Rahman, Ibrahim Gul and Amjad NabiSection of Cardiology, Department of Medicine The Aga KhanUniversity Hospital, Karachi.Correspondence: Dr. Muhammad Nasir Rahman, AssistantProfessor and Consultant, Interventional Cardiologist, Sectionof Cardiology, Department of Medicine, The Aga Khan UniversityHospital, Stadium Road, Karachi.E-mail: nasir.rahman@aku.eduReceived: April 29, 2016;   Accepted: January 03, 2017.

Very Late Stent Thrombosis: Is There Any Limit, When to Stop Antiplatelet Therapy?

https://ecommons.aku.edu/cgi/viewcontent.cgi?article=1094&amp;context=pakistan_fhs_mc_med_cardiol

Very Late Stent Thrombosis: Is There Any Limit, When to Stop Antiplatelet Therapy?

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