Stent Thrombosis


Article Author:
Kalgi Modi
Michael Soos


Article Editor:
Kunal Mahajan


Editors In Chief:
Marie Amma
Jennifer Barrow
Darcy Duncan


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
7/4/2019 6:22:33 PM

Introduction

Stent thrombosis is one of the fatal complications of the percutaneous coronary intervention if it occurs acutely. It is also known as intraprocedural abrupt vessel closure and acute stent thrombosis. [1][2][3]Academic Research Consortium is an academic collaboration between the United States and Europe to universally define stent thrombosis based on the timing of the stent thrombosis and the level of certainty of the event.

Definition  based on the timing of stent thrombosis is as follows:

The acute stent thrombosis occurs between zero to 24 hours after coronary stent implantation. The subacute stent thrombosis occurs between 24 hours to 30 days after coronary stent implantation. Late stent thrombosis occurs between 30 days to one year after coronary stent implantation. Finally,  very late stent thrombosis occurs 1 year after coronary stent implantation.[4]

The definition of stent thrombosis based on the certainty of the event is as follows:

Definite stent thrombosis is confirmed when there is angiographic confirmation of stent thrombosis.

The presence of a thrombus that originates in the stent or the segment 5 mm proximal or distal to the stent, and the presence of at least one of the following criteria within a 48-hour period:

  • Acute onset of ischemic symptoms at rest
  • New ischemic ECG changes 
  • Typical rise and fall in cardiac biomarkers
  • Nonocclusive thrombus
  • Intracoronary thrombus
  • Occlusive thrombus
  • TIMI 0 or TIMI 1 flow intrastent or proximal to a stent up to the most adjacent proximal side branch or main branch.

Definite stent thrombosis is confirmed when there is a pathological confirmation of stent thrombosis.

Evidence of recent thrombus within the stent at autopsy or by examination of tissue retrieved following thrombectomy.

Probable stent thrombosis is considered to have occurred after intracoronary stenting in the following cases:

  • Any unexplained death within the first 30 days
  • Irrespective of the time after the index stenting, any myocardial infarction due to acute ischemia in the distribution of the implanted stent without angiographic evidence of stent thrombosis and the absence of any other obvious cause.

Possible cause of stent thrombosis is considered to have occurred with any unexplained death from 30 days after intracoronary stenting until the end of follow-up.

Etiology

Large randomized trials and registry have identified patient/lesion, procedural, or stent factors related to stent thrombosis. [5][6]Champion-phoenix trial identified Non-ST-elevation myocardial infarction (NSTEMI) and ST-elevation myocardial infarction (STEMI) at presentation, angiographic thrombus burden, and total stent length as independent predictors of acute stent thrombosis.  An acuity trial revealed diabetes, renal insufficiency, Duke jeopardy score, final stent minimal luminal diameter, preprocedural thienopyridine administration, baseline hemoglobin, and extent of coronary artery disease as independent factors associated with early stent thrombosis. In an intravascular ultrasound (IVUS) substudy of the Horizon AMI trial, the small cross-sectional area of less than 5 mm, malposition of stent struts, plaque prolapse or protrusion, edge dissection, and residual stenosis played significant roles in predicting early stent thrombosis. Also, bifurcation stenting contributed to stent thrombosis. The Triton TIMI 38 trial showed that patients with STEMI are at higher risk of stent thrombosis regardless of stent type and that more potent antiplatelet therapy such as Prasugrel reduced that risk by 50%.

Epidemiology

Stent thrombosis has been recognized from the early era of stent deployment with an incidence as high as 16% in older studies. Fifteen to 30% of the patients with stent thrombosis die within 30 days of the event. Acetylsalicylic acid (ASA), dipyridamole, coumadin, and dextran were tried in early stenting era to prevent the event. With the current practice of dual antiplatelet therapy and high-pressure inflation has significantly decreased incidence to 0.7% in one year and about 0.2% to 0.6% the year after that. The rate is lower for elective percutaneous intervention (PCI) (0.3% to 0.5%) but as high as 3.4% for acute coronary syndrome. There has been overall no significant difference between the rate of stent thrombosis between bare-metal stents and eluting drug stents. Only the timing of event varies. The bare metal stent tends to have an early event with a peak around 30 days compared to drug-eluting stents around three months to even later depending on the drug-coated. [7][8]

Pathophysiology

Virchow’s triad explains the major factors that lead to stent thrombosis. First, stasis and turbulence caused by an under-expanded stent, a stent in a small vessel, or a long lesion. Second, injury or endothelial disruption caused by edge dissection or delayed healing with eluting drug stents. Finally, hypercoagulability caused by congenital or acquired or nonresponder.

History and Physical

A thorough history, medication compliance review, laboratory testing for P2Y12 resistance, a 12 lead EKG, echocardiogram looking for a new wall motion abnormality, and laboratory testing of cardiac enzymes is recommended for initial evaluation of a patient with recent percutaneous coronary intervention presenting with angina. Universally, 60% of the patients with stent thrombosis present with STEMI and 40% with NSTEMI or unstable angina. Patients with STEMI, in the context of stent thrombosis, have greater rates of in-hospital mortality  (17.4%). Patients with early stent thrombosis are more likely to develop cardiogenic shock than to develop late or very late stent thrombosis. It is very unlikely that patient with nonacute coronary syndrome presentation would have evidence of stent thrombosis on subsequent coronary angiogram performed.

Evaluation

High clinical suspicion is the most important evaluation for a patient presenting with angina and recent history of coronary stenting. The patient is usually evaluated with a history, physical, ECG, echocardiogram, and cardiac enzymes. Almost all patients with STEMI undergo urgent coronary angiography.

Treatment / Management

During angiography, a prompt aspiration thrombectomy or angioplasty should be performed to restore patency of the thrombosed vessel. Compliance and drug resistance should be evaluated. More potent antiplatelet therapy should be considered, for example, prasugrel or ticagrelor. [9][10][11]The current recommendation is to continue the dual antiplatelet drug therapy for one year after drug-eluting stent placement and at least one month following bare metal stent. The stent should be assessed with either IVUS or optical coherence tomography (OCT) to determine stent apposition, expansion, and the presence of edge dissections. Optimization of stent deployment with appropriate postulation and treatment of edge dissections with additional stents are imperative to prevent repeat stent thrombosis. Additional stent implantation should be avoided if possible because each millimeter of the stent increases the probability of stent thrombosis.

Enhancing Healthcare Team Outcomes

When patients with stents present with chest pain to the primary care provider, internist, and nurse practitioner, one should always consider stent thrombosis. These patients should be immediately referred to the cardiologist for further investigation and treatment. Stent thrombosis when it occurs acutely can be fatal if not treated right away. The triage nurse should be aware of this condition and immediately admit the patient and consult with the emergency department physician. The prognosis depends on many factors including patient age, duration of thrombosis, number of stents involved and response to medical treatment. In some cases, an urgent coronary bypass is required.[12][13] [14](Level II)


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Stent Thrombosis - Questions

Take a quiz of the questions on this article.

Take Quiz
Which of the following increases the risk of in-stent thrombosis increased?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is not a strategy in the management of stent thrombosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
An 83-year-old African American male with a past medical history of severe left ventricular systolic dysfunction and multivessel coronary artery disease presents with a non-ST segment elevation myocardial infarction and cardiac arrest. A coronary angiogram reveals heavy calcification and greater than 90% stenosis in the mid-right circumflex artery. The lesion was pre-dilated with a cutting balloon and followed by placement of overlapping 3 x 30-millimeter and 3 x 12-millimeter drug-eluting stents. Stents were placed post-dilatation with the stent balloon. The post images are shown in the figure below. The complication was treated with a Graftmaster stent. Post images showed no evidence of residual disease or dissection. The patient presented 2 hours later with an inferior STEMI. The right coronary artery was totally occluded. What is the cause of the inferior STEMI?

(Move Mouse on Image to Enlarge)
  • Image 5698 Not availableImage 5698 Not available
    Contributed by Kalgi Modi
Attributed To: Contributed by Kalgi Modi



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 59-year-old male is brought to the emergency department (ED) by emergency medical services (EMS) after being found unresponsive at home by family. Upon discovery, the patient is not displaying spontaneous respiration and is found to be pulseless. Basic life support protocols were performed by a friend until the arrival of EMS at which time advanced cardiac life support protocols (ACLS) were enacted. EMS obtained history from a friend who notes that the patient has a medical history of hypertension, diabetes, and smoking. She notes that the patient was recently discharged after being hospitalized for chest pain and that during his stay, he underwent cardiac catheterization and had two drug-eluting stents placed. Upon arrival to the ED, ACLS protocols are continued by ED staff. Unfortunately, after 40 minutes of ACLS protocols, EMS and ER staff are unable to obtain return of spontaneous circulation, and the patient is declared deceased. The family is notified and is asking what the most likely cause of death was. Which of the following best describes the cause of death in this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 59-year-old male presents to the emergency department (ED) via emergency medical services (EMS) with typical angina symptoms that started about 45 minutes earlier. His pain is substernal without radiation, worsens with exertion, and improves with nitroglycerin. Upon arrival to the ED, a stat electrocardiogram reveals 2 mm ST elevations in leads II, III, and aVF. The case is reviewed with the intensivist on call who notes that the patient was recently discharged after being hospitalized for chest pain. Prior to discharge, he had undergone cardiac catheterization and had one drug-eluting stent placed in his right coronary artery (RCA). The patient is taken emergently to cardiac catheterization and thrombectomy is performed after soft plaque is found occluding the RCA. What is the most likely diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Stent Thrombosis - References

References

Longobardo L,Mattesini A,Valente S,Di Mario C, OCT-guided Percutaneous Coronary Intervention in Bifurcation Lesions. Interventional cardiology (London, England). 2019 Feb;     [PubMed]
Piranavan P,Kaur NJ,Marmoush F,Burton A,Hannan J, Ticagrelor-induced Angioedema After Percutaneous Coronary Intervention in a Patient with a History of Ischemic Stroke and Low Response to Clopidogrel: A Rare Dilemma. Cureus. 2018 Dec 11;     [PubMed]
Lee SN,Moon D,Moon KW,Yoo KD, The Glasgow prognostic score as a significant predictor of clinical outcomes in patients with acute coronary syndrome. Journal of cardiology. 2019 Mar 13;     [PubMed]
Che QQ,Wu Q,Liang YB,Sun RM,Lyu QW,Ma JL,Hu H,Lin X,Xu GL,Sun SG,Zhang C,Wang QY,Yu J,Bai F, [Meta-analysis on safety and efficacy of dual antiplatelet therapy combining with proton pump inhibitors for patients after percutaneous coronary intervention]. Zhonghua xin xue guan bing za zhi. 2019 Feb 24;     [PubMed]
Guo C,Li M,Lv YH,Zhang MB,Wang ZL, De-escalation versus standard dual antiplatelet therapy in patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis. Platelets. 2019 Feb 13;     [PubMed]
Wang Z,Xie Q,Xiang Q,Gong Y,Jiang J,Cui Y, Predictive Value of Methods Measuring Platelet Activation for Ischemic Events in Patients Receiving Clopidogrel: A Meta-analysis. Current pharmaceutical design. 2019 Feb 5;     [PubMed]
Kim YH,Her AY,Jeong MH,Kim BK,Hong SJ,Ahn CM,Kim JS,Ko YG,Choi D,Hong MK,Jang Y, A comparison of the impact of current smoking on 2-year major clinical outcomes of first- and second-generation drug-eluting stents in acute myocardial infarction: Data from the Korea Acute Myocardial Infarction Registry. Medicine. 2019 Mar;     [PubMed]
Zhao XY,Li JX,Tang XF,Xu JJ,Song Y,Jiang L,Chen J,Song L,Gao LJ,Gao Z,Qiao SB,Yang YJ,Gao RL,Xu B,Yuan JQ, Validation of Predictive Value of Patterns of Nonadherence to Antiplatelet Regimen in Stented Patients Thrombotic Risk Score in Chinese Population Undergoing Percutaneous Coronary Intervention: A Prospective Observational Study. Chinese medical journal. 2018 Nov 20;     [PubMed]
Redfors B,Dworeck C,Haraldsson I,Angerås O,Odenstedt J,Ioanes D,Petursson P,Völz S,Albertsson P,Råmunddal T,Persson J,Koul S,Erlinge D,Omerovic E, Pretreatment with P2Y12 receptor antagonists in ST-elevation myocardial infarction: a report from the Swedish Coronary Angiography and Angioplasty Registry. European heart journal. 2019 Mar 9;     [PubMed]
Guy JM,Wilson M,Schnell F,Chevalier L,Verdier JC,Corone S,Doutreleau S,Kervio G,Carré F, Incidence of major adverse cardiac events in men wishing to continue competitive sport following percutaneous coronary intervention. Archives of cardiovascular diseases. 2019 Jan 3;     [PubMed]
Capodanno D,Alfonso F,Levine GN,Valgimigli M,Angiolillo DJ, ACC/AHA Versus ESC Guidelines on Dual Antiplatelet Therapy: JACC Guideline Comparison. Journal of the American College of Cardiology. 2018 Dec 11;     [PubMed]
Abdelaziz HK,Abuomara HZ,Ali MH,Eichhofer J,Patel B,Saad M, Routine use of optical coherence tomography in bioresorbable vascular scaffold implantation: insights on technique optimization and long-term outcomes. Coronary artery disease. 2019 Mar 13;     [PubMed]
Agarwal N,Mahmoud AN,Mojadidi MK,Golwala H,Elgendy IY, Dual versus triple antithrombotic therapy in patients undergoing percutaneous coronary intervention-meta-analysis and meta-regression. Cardiovascular revascularization medicine : including molecular interventions. 2019 Mar 5;     [PubMed]
Hommels TM,Hermanides RS,Rasoul S,Berta B,IJsselmuiden AJJ,Jessurun GAJ,Benit E,Pereira B,De Luca G,Kedhi E, Everolimus-eluting bioresorbable scaffolds for treatment of coronary artery disease in patients with diabetes mellitus: the midterm follow-up of the prospective ABSORB DM Benelux study. Cardiovascular diabetology. 2019 Mar 9;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Nurse-Adult Medical Surgical RN. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Nurse-Adult Medical Surgical RN, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Nurse-Adult Medical Surgical RN, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Nurse-Adult Medical Surgical RN. When it is time for the Nurse-Adult Medical Surgical RN board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Nurse-Adult Medical Surgical RN.