Thrombose coronaire très tardive par fracture du stent actif. Cas clinique et revue de la littérature

The superiority of drug-eluting stents in reducing the risk of in-stent restenosis compared to bare-metal stents is no longer challenged. Nevertheless, the drug-eluting stents may carry long-term risk of late and very late stent thrombosis. The promoting factors of this complication are usually divided into three chapters depending on the patient, the procedure and the stent. Indeed, the literature has reported several parameters related to the stent itself, such as its length, the malapposition, its diameter, but also more rarely the occurrence of stent fracture. We present the case of a patient admitted for myocardial infarction after a very late thrombosis of Cypher drug-eluting stent four years after its implantation and related to stent fracture.     

Very late stent fracture associated with a sirolimus-eluting stent

Late stent thrombosis (>1 year after implantation) is a recognised complication involving drug-eluting stents. Stent fracture is increasingly being reported as a complication of drug-eluting stent, and in particular sirolimus-eluting stent use. We report the case of very late sirolimus-eluting stent fracture resulting in an acute coronary syndrome. This case report highlights the need for greater awareness and post-marketing surveillance to detect a potential mechanism for late stent thrombosis in the drug-eluting stent era.     

Thrombosis and acute myocardial infarction as consequences of very late stent malapposition after implantation of a drug-eluting stent

The use of drug-eluting stents (DES) provides early and late benefits demonstrated by angiographic and clinical outcomes. Here we report a case of late stent thrombosis and acute myocardial infarction caused by late stent malapposition (LSM) of a DES at 16 months after the procedure. We successfully treated the patient with balloon angioplasty after intravenous thrombolytic therapy. This case illustrates that a LSM can develop at any time after DES implantation and can result in acute coronary syndrome. Therefore, clinicians should be aware of the possibility of late cardiac events after implantation of DES.     

Multiple Stent Fractures After Everolimus-Eluting Stent Implantation Causing Acute Myocardial Infarction: A Case Report

Stent fracture is an uncommon complication of drug-eluting stent implantation, but it has a clinical significance because of its potential association with adverse cardiac events such as in-stent restenosis, target lesion revascularization, and stent thrombosis. Multiple stent fractures account for a small proportion, but they may lead to more serious complications. Newer generation drug-eluting stents are designed for improved safety and efficacy compared with early generation drug-eluting stents. Multiple stent fractures after newer generation drug-eluting stent implantation are a rare case.We report a case of 25-year-old male who presented with acute myocardial infarction caused by multiple stent fractures after everolimus-eluting stents implantation and was treated by balloon angioplasty.Physicians should be aware of the possibility of multiple stent fractures even after newer generation drug-eluting stent implantation.     

The conundrum of late and very late stent thrombosis following drug-eluting stent implantation

PURPOSE OF REVIEW: Drug-eluting stents reduce restenosis compared with bare metal stents, but there is growing concern that drug-eluting stents may lead to higher rates of late stent thrombosis, a rare and potentially catastrophic complication following stenting. RECENT FINDINGS: While the data on the risk of late stent thrombosis are not definitive, several general conclusions may be drawn from the available data. Late thrombosis, while associated with high mortality and morbidity, is an uncommon complication of both drug-eluting stents and bare metal stents. Randomized trials of approved drug-eluting stents versus bare metal stents have shown additional cases of late stent thrombosis in drug-eluting stents, but no significant difference in the cumulative incidence of stent thrombosis, myocardial infarction, or cardiac death at 4 years of follow-up. Observational studies suggest higher very late stent thrombosis incidence, but the relative risks of drug-eluting stents versus bare metal stents in specific high-risk groups require further study. Although the etiology of late stent thrombosis is multifactorial, premature discontinuation of clopidogrel appears to be the most important risk factor. SUMMARY: Long-term follow-up of patients after coronary stenting has identified stent thrombosis as a rare but serious event. Ongoing clinical trials in broader patient populations will be helpful to understand the risk of late stent thrombosis with greater certainty.     

Cardiogenic shock caused by simultaneous subacute stent thrombosis after implantation of sirolimus-eluting stents

Stent thrombosis is a feared complication of percutaneous coronary intervention, although there is a low incidence of thrombotic events following drug-eluting stent implantation. We report a case with cardiogenic shock complicated by acute myocardial infarction due to simultaneous subacute stent thrombosis occurring 3 days after implantation of two sirolimus-eluting stents in the proximal left anterior descending artery (LAD) and in the proximal right coronary artery (RCA).     

Thrombose très tardive d’un stent nu dix ans après son implantation : à propos d’une observation

Very late thrombosis occurring after bare-metal stent (BMS) implantation is a rare complication. It differs from very late thrombosis of drug-eluting stents in terms of both frequency and pathophysiological mechanism. We report a case of very late stent thrombosis of a bare-metal stent 10 years after his implantation for treatment of a myocardial infarction. The patient had a new acute coronary syndrome without persistent ST-segment elevation related to bare-metal stent thrombosis. He was treated by thrombo-aspiration and implantation of a new bare-metal stent.     

Drug-eluting stent implantation in ST-elevation acute myocardial infarction: 'real world' 30-day and mid-term results.

Primary percutaneous coronary intervention (PCI) with stent implantation is the preferred method of reperfusion for ST-elevation acute myocardial infarction. Concern remains over the use of drug-eluting stents in the acute ST-elevation myocardial infarction setting, with limited published reports on their use for this application. We studied 64 consecutive patients presenting with an acute ST-elevation myocardial infarction who underwent mechanical reperfusion with implantation of a drug-eluting stent. Both sirolimus- and paclitaxel-eluting stents were used. Primary outcome was the occurrence of major adverse cardiac events, defined as death, nonfatal reinfarction or clinically driven target vessel revascularization. Post-procedural success was achieved in 63 patients (98%). In-hospital mortality was 1.6%. During a median follow-up of 234 days, there were no cases of stent thrombosis, reinfarction or reintervention. These findings conducted in a 'real world' practice setting in the United States demonstrate that drug-eluting stent implantation for acute ST-elevation myocardial infarction is safe and effective, with a low rate of major adverse cardiac events during mid-term follow-up.     

Very late bare-metal stent thrombosis. A case report and review of the literature

Stent thrombosis is a catastrophic event characterized by the acute thrombotic occlusion of a previously-stented segment of a coronary artery. It usually presents as an ST-segment elevation myocardial infarction and/or death, and most commonly occurs within the first several weeks after stent placement. Stent thrombosis is classified as either subacute stent thrombosis (SAT), occurring within 30 days of stent placement, or as late stent thrombosis (LST), occurring after 30 days. While very late stent thrombosis (VLST), occurring beyond 1 year, is not uncommon with the use of drug-eluting stents, it is distinctly unusual with the use of bare-metal stents. We report a case of very late thrombosis of a bare-metal stent occurring 717 days after implantation.     

A case of early drug-eluting stent fracture

Although stent fracture following femoro-popliteal intervention is well recognized, coronary stent fracture represents an underrecognized entity. Its incidence is low but it represents an important clinical entity as it may complicate with stent thrombosis causing acute coronary syndromes, or may predispose to instent restenosis. Although coronary stent fracture may involve both bare metal stents (BMS) and drug-eluting stents (DES), a recent analysis of the literature indicates that reports of stent fracture have increased since DES was introduced. Furthermore, chronic stretch at specific vessel sites as bends may lead to late occurrence of fracture. We present the case of a patient with a non-ST-segment elevation acute coronary syndrome caused by the early fracture of an everolimus-eluting stent (Xience?) implanted only three days before.     

Recurrent very late drug-eluting stent thrombosis

In-stent thrombosis is a severe and potentially fatal event. The incidence of this pathological process does not differ significantly after implantation of either bare metal or drug-eluting stents (DESs) in the first month after intervention, but stent thrombosis (ST) continues to occur over a long period of time after implantation of DESs, a phenomenon known as late and very late ST. Multiple predictors of late ST have been identified, and among others, patient's adherence to medical therapy as well as an optimal interventional technique of stent implantation emerge as crucial variables. Scarce data is available about the occurrence of recurrent very late ST. We report three cases of recurrent very late thrombosis of first generation DESs in middle-aged patients with different degrees of coronary artery disease, presenting with acute myocardial infarction.     

国产药物洗脱支架在急诊冠脉介入治疗中导致急性支架内血栓形成的临床分析

目的分析急性ST段抬高型心肌梗死急诊介入治疗应用国产雷帕霉素药物洗脱支架（DES）导致急性支架内血栓形成的临床相关因素。方法回顾性分析我院心内科2005年11月至2007年12月因急性心肌梗死行急诊冠状动脉介入治疗并且置入国产DES支架的429例患者中发生急性支架内血栓形成的7例患者的临床资料、支架释放情况以及术前抗血小板治疗等相关因素。结果7例患者均具有多项心血管危险因素，其梗死相关血管1例为左前降支，6例为右冠状动脉而且均为弥漫长病变、术前服用双重抗血小板药物到支架置入时间为（124．2±3．7）min、支架释放压力为（1261．39±213．78）kpa，有5例患者行高压球囊支架内后扩张，平均扩张压力为（1491．39±169．20）kPa，平均次数为（2．8±1．5）次；血栓发生后有3例患者经重复球囊扩张，1例经再次置入支架，3例静脉滴注替罗非班等治疗好转，无1例死亡。结论国产DES治疗急性ST段抬高型心肌梗死而导致急性支架内血栓形成的患者多具有多重心血管危险因素。其支架内急性血栓形成的原因，可能与梗死相关血管为弥漫长病变，且多为右冠状动脉、术前服用抗血小板治疗不充分、支架释放后多次高压后扩张等因素有关。经再次冠状动脉内介入治疗和使用血小板糖蛋白Ⅱb／Ⅲa受体拮抗剂治疗是安全、有效的。     

A case report of very late thrombosis of coronary bare-metal stent 10 years after stenting

Although late stent thrombosis is not uncommon with the use of drug-eluting stents, it is unusual with the use of bare-metal stents (BMS) because stent endothelialization is considered to be completed 4 weeks after the intervention.(1) A 64 year-old male had undergone percutaneous coronary intervention (PCI) for a proximal left anterior descending (LAD) artery lesion with a BMS and excellent angiographic results were obtained. Two hundred mg of ticlopidine was prescribed for one month and 100 mg of aspirin daily was continued. One year after stent implantation, coronary angiography (CAG) showed no restenosis. Ten years and 7 months after stent implantation, he suffered an acute myocardial infarction due to stent thrombosis. Intra-coronary aspiration thrombectomy was successful. To the best of our knowledge, the longest delayed case of BMS thrombosis is 5 years after stent implantation.(2) Our report demonstrated evidence of the latest reported case of stent thrombosis with the use of a BMS.     

Fractured DES with a patent coronary artery: clinical implications

Recently, reports of stent fracture with focal restenosis have suggested that it is another mechanism of in-stent restenosis after implantation of sirolimus-eluting stents. However, the mechanism by which strut disruption occurs remains unknown. Current reports of in-stent restenosis suggest that fracture of drug-eluting stents is different from bare-metal stents, and can progress to restenosis and reocclusion. We report on a patient with a fractured stent in a patent coronary artery that progressed to diffuse neointimal hyperplasia presenting with acute myocardial infarction 2 years after stent placement.     

Late thrombosis after bare metal stent implantation in a patient with acute coronary syndrome

We present a case of a 47-year-old man with ST-segment-elevation myocardial infarction (STEMI), successfully treated with bare metal stent implantation. After 20 months the patient was readmitted with another episode of STEMI due to in-stent thrombosis following voluntary withdrawal of anti-platelet therapy. The implications of late stent thrombosis after bare metal stent implantation are discussed. We compare this phenomenon with thrombosis after implantation of drug-eluting stents. Various aspects and potential causes of late stent thrombosis are reviewed, especially the issues pertaining the use of anti-platelet therapy and duration of this therapy.     

Myocardial infarction due to late stent thrombosis following epileptic convulsive seizures

We report the first case in the literature of acute myocardial infarction due to very late (5 years) drug-eluting stent (DES) thrombosis presenting with inferior ST-elevation myocardial infarction immediately after epileptic convulsive seizures in a patient with known coronary artery disease. A bare-metal stent had been implanted in the left anterior descending coronary artery in 2002, and a drug-eluting stent implanted in the right coronary artery in 2003. We discuss the possible pathogenetic mechanisms implied in convulsive epileptic crisis resulting in development of very late DES thrombosis.     

Late stent thrombosis thirteen months after drug-eluting stent implantation

We present a case of a very late stent thrombosis which occurred 13 months after drug-eluting stent (DES) implantation. The DES was off-label used in a high-risk patient and was followed by 12-month clopidogrel administration. One month after the drug discontinuation the stent thrombosis occurred, resulting in acute myocardial infarction. The patient was successfully treated with balloon coronary angioplasty and was advised to use clopidogrel indefinitely.     

Late coronary stent thrombosis and clopidogrel

The existence of late coronary stent thrombosis is a topical issue in cardiology today. The synoptic article discusses current definition of the above phenomenon, its delimitation in time and actual incidence. Based on data from available observation and randomised studies, long-term safety of conventional bare metal and drug-eluting stents is evaluated, as well as the safety profile following implantation. The length of thienopyridin treatment after percutaneous coronary intervention (PCI) varies according to the type of stent used. While a conventional bare metal stent (BMS) implant provides long-term safety with one month treatment, the implantation of a drug-eluting stent (DES) should be complemented with a 12-month period of clopidogrel administration. This approach may be in the future influenced by further progress in drug-eluting stents development and by prospectively acquired information on long-term administration of clopidogrel to such patients.     

Very late thrombosis after drug-eluting stents.

Stent thrombosis is a rare but potentially fatal complication of percutaneous treatment of coronary disease. Its occurrence after drug eluting stent (DES) placement has raised concerns, especially when it occurs late after the stent implantation. The mechanisms of late thrombosis after DES have yet to be completely understood. By means of serial angiography and intravascular (IVUS) images we described a relatively new and unusual vessel response to drug-eluting stents (e.g. huge positive remodeling in all vessel extension), leading to impressive late-acquired incomplete stent apposition and finally causing stent thrombosis and acute myocardial infarction. After describing the two cases, one after Cypher stent implantation and one after Taxus stent implantation, we briefly reviewed the literature available on stent thrombosis with special emphasis on its late occurrence.     

Very late drug-eluting stent thrombosis post exercise stress echocardiogram

Stent thrombosis, although a rare event, has been the object of considerable interest because of its attendant morbidity and mortality and has come into focus with the advent of drug-eluting stents. We report a case of very late drug-eluting stent thrombosis occurring immediately after an exercise stress echocardiogram, in a patient who, 2 years earlier, had undergone primary percutaneous coronary intervention (PCI) for ST segment elevation myocardial infarction (STEMI). Similar cases reported in the literature and the possible mechanisms of stent thrombosis associated with exercise testing are reviewed.