Coronary stent thrombosis: Difference between revisions
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'''Editors-In-Chief:''' Allen Jeremias, M.D. ; Don Cutlip, M.D. | '''Editors-In-Chief:''' Allen Jeremias, M.D., SUNY; Don Cutlip, M.D. Beth Israel Deaconess Medical Center, Harvard | ||
'''Associate | '''Associate Editors-In-Chief:''' Priyantha Ranaweera, M.D.; William J. Gibson, MIT | ||
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Revision as of 22:38, 17 January 2009
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Editors-In-Chief: Allen Jeremias, M.D., SUNY; Don Cutlip, M.D. Beth Israel Deaconess Medical Center, Harvard
Associate Editors-In-Chief: Priyantha Ranaweera, M.D.; William J. Gibson, MIT
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Introduction
Stent thrombosis (ST) is a rare but devastating complication of coronary artery stenting that is associated with a high rate of morbidity and mortality [1] [2] [3] [4]
Over the years stent thrombosis of bare metal stents (BMS) has been minimised by refining stent design, adopting optimal stenting strategies and improved antiplatelet medication usage from a massive 24% in some studies to [5] a rare and acceptable 0.5-1.5% in the current environment.
Following the approval by the FDA, the drug eluting stents (DES) largely replaced BMS, driven solely by the reduced revascularization with relatively little attention paid to the issue of ST.
Increased usage of DES and continued presentation of paients with ST beyond the first few months of implantation, coupled with the widespread awareness of ST, have led to a steady and increased stream of reporting of ST in DES.
Recent description of frequent subclinical insitu thrombus formation within DES in the coronaries by Katani et al, not only took the medical community by surprise but afforded a first hand in-vivo glimpse at the stent site itself. It should be noted that the term coronary stent thrombosis (ST) is commonly used for clinically significant episodes. [6] [7]
In this context, clinically significant ST appears to be a rare complication with devastating consequences if left untreated emergently, though the mileu for such probably exists in a much larger population.
This process should not be confused with restenosis, a fibro-proliferative disorder which is associated with recurrent angina and ischemia but uncommonly with myocardial infarction or death.
Definitions - coronary stent thombosis (ST)
Mechanism and pathophysiology of coronary stent thrombosis (ST)
Incidence of coronary stent thrombosis (ST) in bare metal stents (BMS)
Incidence of coronary stent thrombosis (ST) in drug eluting stents (DES)
Incidence of drug eluting stent thrombosis (ST) in relation to antiplatelet medication use
State of the art
At the request of the FDA, four major drug companies and four major device companies are jointly investigating the best strategy to avoid clot formation in patients that have received stents. The $100 million, four-year study of 20,000 patients will specifically examine whether patients should remain on blood-thinners for 1 or 2.5+ years after PCI. Companies involved include: Bristol-Myers Squibb, Sanofi-Aventis, Eli Lilly, Daiichi Sankyo, Abbott, Medtronic, Boston Scientific, and Johnson & Johnson. This study was presented at TCT 2008 by Dr. Laura Mauri, a co-principal investigator of the study.[8]
References
- ↑ Cutlip DE, Baim DS, Ho KK, et al. Stent thrombosis in the modern era: a pooled analysis of multicenter coronary stent clinical trials. Circulation 2001;103:1967-71.
- ↑ Moussa I, Di Mario C, Reimers B, Akiyama T, Tobis J, Colombo A. Subacute stent thrombosis in the era of intravascular ultrasound-guided coronary stenting without anticoagulation: frequency, predictors and clinical outcome. J Am Coll Cardiol 1997;29:6-12.
- ↑ Karrillon GJ, Morice MC, Benveniste E, et al. Intracoronary stent implantation without ultrasound guidance and with replacement of conventional anticoagulation by antiplatelet therapy. 30-day clinical outcome of the French Multicenter Registry. Circulation 1996;94:1519-27.
- ↑ Orford JL, Lennon R, Melby S, et al. Frequency and correlates of coronary stent thrombosis in the modern era: analysis of a single center registry. J Am Coll Cardiol 2002;40:1567-72.
- ↑ Serruys PW, Strauss BH, Beatt KJ, Bertrand ME, Puel J, Rickards AF, Meier B, Goy JJ, Vogt P, Kappenberger L. Angiographic follow-up after placement of a self-expanding coronary-artery stent. N Engl J Med. 1991;324:13–17.
- ↑ Sotirios Tsimikas, Drug-Eluting Stents and Late Adverse Clinical Outcomes; Lessons Learned, Lessons Awaited; editorial comment; JACC Vol. 47, No. 10, 2006
- ↑ Kotani, J, Awata, M, Nanto, S, et al. Incomplete neointimal coverage of sirolimus-eluting stents: angioscopic findings. J Am Coll Cardiol 2006; 47:2108.
- ↑ http://online.wsj.com/article/SB122411707038238773.html?mod=rss_whats_news_us_busines
Additional Resources
- Singh M Et al. Influence of coronary thrombus on outcome of percutaneous coronary angioplasty in the current eta (the mayo clinc experince). Am J Cardiol 2001;88:1091-6
- White CJ et al. Coronary thrombi increase PTCA risk. Angioscopy as a clinicla tool. Circulation 1996;93:253-8
- G Sianos, et al. Angiographic stent thrombosis after routine use of drug eluting stents in ST -Segement elevation myocardial infarction, the importance of thrombus burden. JACC, Vol 50, No 7, 2007
- C. Spaulding, et al. Sirolimus-Eluting versus Uncoated Stents in acute myocardial infarction, N Engl J Med 2006;355:1093-104.
- Menichelli M . Sirolimus stent versus bare stent in acute myocardial infarction trail, Presented at European Percutaneou Cororanry Revascularizaton 2006.