Intraprocedural stent thrombosis: Difference between revisions

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* The frequency of occurrence currently ranges between 0.5 – 1.7% of all PCI procedures.
* The frequency of occurrence currently ranges between 0.5 – 1.7% of all PCI procedures.


* According to Brener et al., IPST occurred in 0.7% of PCI when frame-by-frame analysis was done for 6591 patients enrolled in the ACUITY and HORIZONS-AMI (Harmonizing Outcomes With Revascularization And Stents In Acute Myocardial Infarction) trials.<ref name="Brener-2013">{{Cite journal  | last1 = Brener | first1 = SJ. | last2 = Cristea | first2 = E. | last3 = Kirtane | first3 = AJ. | last4 = McEntegart | first4 = MB. | last5 = Xu | first5 = K. | last6 = Mehran | first6 = R. | last7 = Stone | first7 = GW. | title = Intra-procedural stent thrombosis: a new risk factor for adverse outcomes in patients undergoing percutaneous coronary intervention for acute coronary syndromes. | journal = JACC Cardiovasc Interv | volume = 6 | issue = 1 | pages = 36-43 | month = Jan | year = 2013 | doi = 10.1016/j.jcin.2012.08.018 | PMID = 23266233 }}</ref>  Similarly, Xu and colleagues documented an IPST rate of 1.2% in 2013 following enrollment of 1901 patients.<ref name="Xu-2013">{{Cite journal  | last1 = Xu | first1 = Y. | last2 = Qu | first2 = X. | last3 = Fang | first3 = W. | last4 = Chen | first4 = H. | title = Prevalence, correlation and clinical outcome of intra-procedural stent thrombosis in patients undergoing primary percutaneous coronary intervention for acute coronary syndrome. | journal = J Interv Cardiol | volume = 26 | issue = 3 | pages = 215-20 | month = Jun | year = 2013 | doi = 10.1111/joic.12029 | PMID = 23551235 }}</ref>  The incidence of IPST was 0.7% according to both Biondi-Zoccai et al. who reviewed the frequency of IPST in 1320 patients less than 75 years old undergoing PCI with first generation DES and to Chieffo et al. who enrolled 670 patients undergoing elective DES.<ref name="pmid15148281">{{cite journal| author=Chieffo A, Bonizzoni E, Orlic D, Stankovic G, Rogacka R, Airoldi F et al.| title=Intraprocedural stent thrombosis during implantation of sirolimus-eluting stents. | journal=Circulation | year= 2004 | volume= 109 | issue= 22 | pages= 2732-6 | pmid=15148281 | doi=10.1161/01.CIR.0000131890.83839.5B | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15148281  }} </ref><ref name="pmid15950573">{{cite journal| author=Biondi-Zoccai GG, Sangiorgi GM, Chieffo A, Vittori G, Falchetti E, Margheri M et al.| title=Validation of predictors of intraprocedural stent thrombosis in the drug-eluting stent era. | journal=Am J Cardiol | year= 2005 | volume= 95 | issue= 12 | pages= 1466-8 | pmid=15950573 | doi=10.1016/j.amjcard.2005.01.099 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15950573  }} </ref> Finally, 1.7% of 181 patients had IPST when evaluating DES implantation in bifurcation lesions using “crush technique” by Ge and colleagues in 2005.<ref name="pmid16098424">{{cite journal| author=Ge L, Airoldi F, Iakovou I, Cosgrave J, Michev I, Sangiorgi GM et al.| title=Clinical and angiographic outcome after implantation of drug-eluting stents in bifurcation lesions with the crush stent technique: importance of final kissing balloon post-dilation. | journal=J Am Coll Cardiol | year= 2005 | volume= 46 | issue= 4 | pages= 613-20 | pmid=16098424 | doi=10.1016/j.jacc.2005.05.032 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16098424  }} </ref>
* According to Brener et al., IPST occurred in 0.7% of PCI when frame-by-frame analysis was done for 6591 patients enrolled in the ACUITY and HORIZONS-AMI (Harmonizing Outcomes With Revascularization And Stents In Acute Myocardial Infarction) trials.<ref name="Brener-2013">{{Cite journal  | last1 = Brener | first1 = SJ. | last2 = Cristea | first2 = E. | last3 = Kirtane | first3 = AJ. | last4 = McEntegart | first4 = MB. | last5 = Xu | first5 = K. | last6 = Mehran | first6 = R. | last7 = Stone | first7 = GW. | title = Intra-procedural stent thrombosis: a new risk factor for adverse outcomes in patients undergoing percutaneous coronary intervention for acute coronary syndromes. | journal = JACC Cardiovasc Interv | volume = 6 | issue = 1 | pages = 36-43 | month = Jan | year = 2013 | doi = 10.1016/j.jcin.2012.08.018 | PMID = 23266233 }}</ref>  Similarly, Xu and colleagues documented an IPST rate of 1.2% in 2013 following enrollment of 1901 patients.<ref name="Xu-2013">{{Cite journal  | last1 = Xu | first1 = Y. | last2 = Qu | first2 = X. | last3 = Fang | first3 = W. | last4 = Chen | first4 = H. | title = Prevalence, correlation and clinical outcome of intra-procedural stent thrombosis in patients undergoing primary percutaneous coronary intervention for acute coronary syndrome. | journal = J Interv Cardiol | volume = 26 | issue = 3 | pages = 215-20 | month = Jun | year = 2013 | doi = 10.1111/joic.12029 | PMID = 23551235 }}</ref>  The incidence of IPST was 0.7% according to both Biondi-Zoccai et al. who reviewed the frequency of IPST in 1320 patients less than 75 years old undergoing PCI with first generation DES and to Chieffo et al. who enrolled 670 patients undergoing elective DES.<ref name="pmid15148281">{{cite journal| author=Chieffo A, Bonizzoni E, Orlic D, Stankovic G, Rogacka R, Airoldi F et al.| title=Intraprocedural stent thrombosis during implantation of sirolimus-eluting stents. | journal=Circulation | year= 2004 | volume= 109 | issue= 22 | pages= 2732-6 | pmid=15148281 | doi=10.1161/01.CIR.0000131890.83839.5B | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15148281  }} </ref><ref name="pmid15950573">{{cite journal| author=Biondi-Zoccai GG, Sangiorgi GM, Chieffo A, Vittori G, Falchetti E, Margheri M et al.| title=Validation of predictors of intraprocedural stent thrombosis in the drug-eluting stent era. | journal=Am J Cardiol | year= 2005 | volume= 95 | issue= 12 | pages= 1466-8 | pmid=15950573 | doi=10.1016/j.amjcard.2005.01.099 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15950573  }} </ref>  
* Finally, 1.7% of 181 patients had IPST when evaluating DES implantation in bifurcation lesions using “crush technique” by Ge and colleagues in 2005.<ref name="pmid16098424">{{cite journal| author=Ge L, Airoldi F, Iakovou I, Cosgrave J, Michev I, Sangiorgi GM et al.| title=Clinical and angiographic outcome after implantation of drug-eluting stents in bifurcation lesions with the crush stent technique: importance of final kissing balloon post-dilation. | journal=J Am Coll Cardiol | year= 2005 | volume= 46 | issue= 4 | pages= 613-20 | pmid=16098424 | doi=10.1016/j.jacc.2005.05.032 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16098424  }} </ref>


==Risk Factors==
==Risk Factors==

Revision as of 03:53, 9 September 2013

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and keywords: IPST

Overview

Intraprocedural stent thrombosis (IPST) is the formation of a new, increasing, or reappearing occlusive or non-occlusive thrombus that occurs during the PCI procedure, and is specifically located within the deployed stent or immediately adjacent to it.[1] It is considered a rare subset of IPTE. Although uncommon, it has been strongly associated with subsequent unfavorable periprocedural outcome.[2]

Pathophysiology

IPST can occur with bare metal stents and DES. Several theories suggest possible explanation to IPST in DES. DES characteristics, such as drug-induced thrombogenicity, whether using sirolimus or paclitaxel, and its in-vitro platelet aggregation effects[3] along with its remarkable lipophilic bioavailability within the coronary milieu,[4] stent platform effect,[5] polymer coating material,[5] and open-cell stent design all seem plausible hypotheses that nonetheless require further validation. Operator-dependent factors, such as adequate stent placement have also been postulated.[6]

Epidemiology and Demographics

  • The frequency of occurrence currently ranges between 0.5 – 1.7% of all PCI procedures.
  • According to Brener et al., IPST occurred in 0.7% of PCI when frame-by-frame analysis was done for 6591 patients enrolled in the ACUITY and HORIZONS-AMI (Harmonizing Outcomes With Revascularization And Stents In Acute Myocardial Infarction) trials.[2] Similarly, Xu and colleagues documented an IPST rate of 1.2% in 2013 following enrollment of 1901 patients.[7] The incidence of IPST was 0.7% according to both Biondi-Zoccai et al. who reviewed the frequency of IPST in 1320 patients less than 75 years old undergoing PCI with first generation DES and to Chieffo et al. who enrolled 670 patients undergoing elective DES.[6][8]
  • Finally, 1.7% of 181 patients had IPST when evaluating DES implantation in bifurcation lesions using “crush technique” by Ge and colleagues in 2005.[9]

Risk Factors

Interestingly, conventional risk factors and correlates of early and late postprocedural stent thrombosis do not seem to be the same as those for IPST.

Natural History, Complications and Prognosis

IPST significantly reduces the overall success rate of PCI, as measured by frequency of achieving TIMI flow grade 3 at the end of index PCI. TIMI flow grade 3 is achieved in 90.9% of patients without IPST vs. 44.7% in patients with IPST thrombosis.[2]

Intraprocedural and follow-up data on patients who experience IPST reveal the most common significant complications. The occurrence of IPST remarkably increases the risk of occurrence of IPTE-related complications. The following table summarizes intra-procedural complications of IPST.[2]

Intraprocedural Complications Patients with IPST Patients without IPST
Slow or no reflow 75.5% 3.2%
Distal Embolization 49% 1.9%
Side branch closure 14.3% 0.6%


Similar to IPTE in general, IPST is an important independent predictor of mortality and morbidity one year post-PCI. One year follow-up data shows a 41.1% rate of death, MI, or TVR in patients who had experienced IPST vs. only 14.5% in patients with no IPST.[2] Other adverse events were also increased in patients with IPST after one year post-PCI, such as postprocedural stent thrombosis, TVR, and non-CABG major bleeding.[7][2]

  1. ↑ Xu Y, Qu X, Fang W, Chen H (2013). "Prevalence, correlation and clinical outcome of intra-procedural stent thrombosis in patients undergoing primary percutaneous coronary intervention for acute coronary syndrome". J Interv Cardiol. 26 (3): 215–20. doi:10.1111/joic.12029. PMID 23551235.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Brener, SJ.; Cristea, E.; Kirtane, AJ.; McEntegart, MB.; Xu, K.; Mehran, R.; Stone, GW. (2013). "Intra-procedural stent thrombosis: a new risk factor for adverse outcomes in patients undergoing percutaneous coronary intervention for acute coronary syndromes". JACC Cardiovasc Interv. 6 (1): 36–43. doi:10.1016/j.jcin.2012.08.018. PMID 23266233. Unknown parameter |month= ignored (help)
  3. ↑ Babinska A, Markell MS, Salifu MO, Akoad M, Ehrlich YH, Kornecki E (1998). "Enhancement of human platelet aggregation and secretion induced by rapamycin". Nephrol Dial Transplant. 13 (12): 3153–9. PMID 9870481.
  4. ↑ McKeage K, Murdoch D, Goa KL (2003). "The sirolimus-eluting stent: a review of its use in the treatment of coronary artery disease". Am J Cardiovasc Drugs. 3 (3): 211–30. PMID 14727933.
  5. ↑ 5.0 5.1 Kereiakes DJ, Choo JK, Young JJ, Broderick TM (2004). "Thrombosis and drug-eluting stents: a critical appraisal". Rev Cardiovasc Med. 5 (1): 9–15. PMID 15029110.
  6. ↑ 6.0 6.1 Chieffo A, Bonizzoni E, Orlic D, Stankovic G, Rogacka R, Airoldi F; et al. (2004). "Intraprocedural stent thrombosis during implantation of sirolimus-eluting stents". Circulation. 109 (22): 2732–6. doi:10.1161/01.CIR.0000131890.83839.5B. PMID 15148281.
  7. ↑ 7.0 7.1 Xu, Y.; Qu, X.; Fang, W.; Chen, H. (2013). "Prevalence, correlation and clinical outcome of intra-procedural stent thrombosis in patients undergoing primary percutaneous coronary intervention for acute coronary syndrome". J Interv Cardiol. 26 (3): 215–20. doi:10.1111/joic.12029. PMID 23551235. Unknown parameter |month= ignored (help)
  8. ↑ Biondi-Zoccai GG, Sangiorgi GM, Chieffo A, Vittori G, Falchetti E, Margheri M; et al. (2005). "Validation of predictors of intraprocedural stent thrombosis in the drug-eluting stent era". Am J Cardiol. 95 (12): 1466–8. doi:10.1016/j.amjcard.2005.01.099. PMID 15950573.
  9. ↑ Ge L, Airoldi F, Iakovou I, Cosgrave J, Michev I, Sangiorgi GM; et al. (2005). "Clinical and angiographic outcome after implantation of drug-eluting stents in bifurcation lesions with the crush stent technique: importance of final kissing balloon post-dilation". J Am Coll Cardiol. 46 (4): 613–20. doi:10.1016/j.jacc.2005.05.032. PMID 16098424.


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