Very late stent thrombosis associated with multiple stent fractures and peri-stent aneurysm formation after sirolimus-eluting stent implantation.

Previous randomized trials have shown that drug-eluting stents (DES) are superior to bare-metal stents in reducing the need for target lesion revascularization, but safety issues with DES have recently been raised. We report a rare case of very late stent thrombosis 35 months after sirolimus-eluting stent implantation associated with delayed 5-segment stent fractures and peri-stent aneurysm formation.     

Late angiographic stent thrombosis after sirolimus-eluting stent implantation.

BACKGROUND: Although drug-eluting stents dramatically reduce revascularization after percutaneous coronary intervention (PCI), it is still unclear whether they increase the risk of stent thrombosis. Late stent thrombosis (>30 days) was a very rare complication after bare metal stent implantation. Four cases of confirmed late angiographic stent thrombosis (LAST) after sirolimus-eluting stent (SES) implantation are presented and the incidence, promoting factors and outcomes of such cases in Japan, where clopidogrel has not been approved, are described. METHODS AND RESULTS: Between September 2004 and March 2006, 725 patients underwent PCI with SES implantation and 679 patients (94%) were clinically followed up (median 271 days). There were 4 cases (0.6%) of LAST (at 60, 180, 215, and 508 days, respectively) after elective SES implantation resulting in myocardial infarction. Three cases occurred soon after antiplatelet therapy discontinuation 3 patients died after LAST events. The incidence of LAST was 0.6%. CONCLUSIONS: LAST is a rare complication, even after SES implantation, at least in patients with appropriate antiplatelet therapy. However, as it can lead to fatal complications, it must be taken into account, especially when antiplatelet therapy is discontinued.     

Late stent thrombosis after implantation of a sirolimus-eluting stent.

Late stent thrombosis in the era of routine high-pressure stent deployment and combined antiplatelet therapy with thienopyridines and aspirin has become a rare but feared complication. We describe a patient with acute myocardial infarction due to late stent thrombosis 6 weeks after deployment of a sirolimus-eluting stent and 2 weeks after the discontinuation of clopidogrel. This is the first report of late thrombosis of a sirolimus-eluting stent.     

药物洗脱支架术后冠状动脉瘤样扩张伴极晚期(近5年)支架内血栓形成一例

1 病例资料 患者男性,63岁,2006年5月因胸痛于我院行冠状动脉造影示：左前降支近段至中段弥漫狭窄,最狭窄处达90%,回旋支、右冠状动脉无明显狭窄.于前降支近段至中段串联置入Cypher 3.5×18.0 mm支架（14 atm×10 s扩张释放）及Cypher 3.5×33.0 mm支架（16 atm×10 s扩张释放）各1枚.     

Simultaneous two-vessel very late stent thrombosis and coronary aneurysm formation after sirolimus-eluting stent implantation: an intravascular ultrasound evaluation

Very late stent thrombosis is a rare but devastating complication. Several factors are known to contribute to its occurrence, and are related to the patient, procedure, lesion and premature discontinuation of antiplatelet therapy. This report describes the case of a 49-year-old patient with simultaneous two-vessel stent thrombosis (left anterior descending and circumflex arteries) 24 months after sirolimus-eluting stent implantation. The importance of intravascular ultrasound is enhanced. The potential contributing factors to the stent thrombosis are analyzed.     

Multiple coronary artery aneurysm formation one year and four years after sirolimus-eluting coronary stent implantation

A 61 years old male patient having the complaint of angina pectoris underwent coronary angiography that revealed critical luminal stenosis at left anterior descending artery (LAD) and diagonal branch. Percutaneous transluminal coronary angioplasty was performed and sirolimus eluting stents (CYPHER; Johnson & Johnson – Cordis) 2.75 ×10 mm and 2.75×10 mm were deployed respectively. One year after the procedure coronary angiography revealed coronary artery aneurysm (CAA) formation in diagonal branch and mild ectasia in LAD stent area. Last coronary angiography four years and three months after initial intervention showed multiple CAA at diagonal branch and LAD. This case report is an example of late formation of CAA by sirolimus-coated coronary stent.     

Late stent thrombosis in patients receiving ticlopidine and aspirin after sirolimus-eluting stent implantation.

BACKGROUND: There is little information about the efficacy of ticlopidine plus aspirin after sirolimus-eluting stent (SES) implantation. METHODS AND RESULTS: The incidence of stent thrombosis was evaluated in 1,029 patients receiving ticlopidine and aspirin after SES deployment. Clinical follow-up was obtained in 98.9% (mean follow-up 17.0+/-7.9 months). Early stent thrombosis was observed in 5 patients (0.49%). There was 1 case each of late (0.1%) and very late stent thrombosis (0.1%). CONCLUSION: Late and very late stent thrombosis in Japanese patients receiving ticlopidine and aspirin after SES deployment occurs infrequently.     

Late acute thrombosis after implantation of sirolimus-eluting stent to treat in-stent restenosis

Drug-eluting stents (DES) have significantly reduced the incidence of in-stent restenosis (ISR) compared to bare metal stents (BMS). However, recent randomized trials comparing DES with BMS reported few cases of late DES thrombosis. We report the case of late sirolimus-eluting stent thrombosis occurring 22 months after its elective implantation in a restenotic BMS and soon after the interruption of combined anti-platelet therapy with aspirin and Clopidogrel.     

Late catch-up phenomenon associated with stent fracture after sirolimus-eluting stent implantation: incidence and outcome

Objective: To examine the long‐term outcome of the stent fracture (SF) and the potential predictive factors contributing to in‐stent restenosis (ISR) in the fractured stent. Background: The SF is thought to be a higher risk of ISR in drug‐eluting stent, although SF does not always develop ISR. Methods: The consecutive 1,228 de novo lesions in 1,079 patients who underwent sirolimus‐eluting stents implantation and assessed by 8 months follow‐up coronary angiography were retrospectively analyzed. Results: One hundred and seventeen SFs (9.5%) were identified in 100 patients and 22 (18.8%) SFs revealed ISR at the first follow‐up. In addition, 16 (13.7%) developed new ISRs from 95 residual SFs without ISR prior to the second follow‐up. Overall, 38 (32.5%) of all 117 SFs developed ISR, and 16 (42.1%) of 38 SFs occurred in a late phase beyond the first 8 months follow‐up. A higher risk of ISR in the SF site was associated with the chronic total occlusion (ISR vs. no ISR: 34.2% vs. 16.5%, P = 0.0304), calcified lesions (55.3% vs. 34.2%, P = 0.0299), and correspondence 89.5% versus 43.0%, P < 0.0001 (SF site occurring at the original target lesion site) in the univariate analysis. The correspondence was identified as the only strong predictive factor for ISR at the SF site according to a multivariate logistic regression analysis (odds ratio 12.6, 95% confidence interval 3.82–53.5, P < 0.0001). Conclusions: SF occurring at the site of the original target lesion was a strong independent predictor of ISR. This indicates the need for a careful, long‐term follow‐up in those situations, even when no significant ISR is initially detected. (J Interven Cardiol 2011;24:165–171)     

Simultaneous subacute stent thrombosis after implantation of sirolimus-eluting stent and bare-metal stent

Simultaneous multivessel stent thrombosis is a rare, but can cause catastrophic clinical results. We report a case occurred ST simultaneously in DES and BMS. Our case demonstrated that the use of multiple stents, irrespective of stent type, in multiple coronary artery lesions should be undertaken with great attention in the patient who has multiple adverse clinical predictors such as AMI.     

Very late stent thrombosis in late stent malapposition after sirolimus-eluting stent implantation

Late stent malapposition (LSM) has been demonstrated to be more common after drug-eluting stent (DES) implantation than after bare-metal stent (BMS) implantation. To date, this unusual intravascular ultrasonic finding after DES implantation, however, has not received enough attention, because previous studies suggested few adverse clinical sequelae from LSM. We present a case of angiographically-confirmed very late stent thrombosis (ST) in LSM after elective implantation of sirolimus-eluting stents. In this 32-year-old male patient, very late ST occurred at 29 months after DES implantation and at 20 months after the identification of LSM. Although this patient had received sufficient dual antiplatelet therapy with aspirin and clopidogrel for more than 1 year, he suffered from ST shortly after the discontinuation of clopidogrel. Thus, patients with LSM may pose a significant risk for very late ST after discontinuation of dual antiplatelet therapy. The findings suggest that dual antiplatelet therapy should be further prolonged in patients with LSM.     

西罗莫司洗脱支架置入术后血栓发生率及相关因素分析

目的观察西罗莫司洗脱支架冠状动脉内置人术后,支架血栓发生率及临床相关因素。方法2006年4月至2007年8月间,156例患者于首都医科大学大兴医院置入西罗莫司洗脱支架（Cypher select和Firebird支架）,84例患者随防1年,72例患者随访半年,明确支架血栓发生情况;分析支架血栓的相关因素及转归。结果早期支架血栓3例（1．92％）,晚期支架血栓1例（0．64％）。4例支架血栓患者多支病变（〉2支）2例,分叉病变2例,弥漫长病变2例。共置入支架6枚,平均1．5枚／人,平均支架直径（2．88±0．38）mm,平均长度（25．5±6．12）mm,支架释放压力（13．33±1．03）atm,一枚支架置入后行后扩张,术后TIMI血流均为3级。1例术后3d出现介入血管急性ST段抬高心肌梗死,爱通立溶栓后再通并出现休克,置入主动脉气囊反搏治疗5d,现病情平稳;2例分别于术后6d及15d猝死;1例于术后81d猝死。结论156例西罗莫司洗脱支架置入后,早期支架血栓3例,晚期支架血栓1例;表现为急性心肌梗死或猝死;多数患者为急性冠状动脉综合征,多支病变、分叉病变、弥漫长病变,因无血管内超声指导可能遗留残余夹层或支架贴壁不全;发生支架血栓患者预后差,死亡率高。     

冠状动脉西罗莫司洗脱支架置入后晚期支架内血栓形成分析

目的分析冠状动脉药物洗脱支架置入后晚期支架内血栓形成的临床相关因素。方法回顾性分析2003年7月至2005年1月我院置入西罗莫司洗脱支架的1304例冠心病患者中发生晚期支架内血栓的8例患者的临床资料、冠状动脉病变特点、支架释放情况以及术后的抗血小板治疗等相关因素。结果8例患者平均年龄（51±10）岁、7例为急性冠状动脉综合征患者且伴有多项心血管病危险因素,仅1例患者伴有左室功能不全,无肾功能不全患者;多支冠状动脉病变患者6例且病变较复杂,包括闭塞、分叉、开口和弥漫长病变;支架释放压力平均（1175.37±167．19）kPa（11．60±1．65atm）,全部患者未用高压球囊进行后扩张;双重抗血小板治疗平均时间为（157．5±41．7）d,1例在停用氯吡格雷第7天、2例在服用阿司匹林和氯吡格雷治疗期间、5例停用氯吡格雷6个月后出现支架内血栓,平均血栓发生时间为术后（450．3±344．7）d,5例表现为急性心肌梗死;1例死亡,5例再次置入西罗莫司洗脱支架,术后随访无症状,1例药物治疗。结论发生晚期支架内血栓的冠心病患者多表现为急性冠状动脉综合征、伴有多项心血管病危险因素;多支、复杂冠状动脉病变;支架低压释放,置入后未行后扩张;双重抗血小板治疗时间短。发生晚期支架内血栓患者预后差,死亡率较高,再次置入西罗莫司洗脱支架是安全、有效的。     

Very late stent thrombosis after sirolimus-eluting stent implantation observed using optical coherence tomography and coronary angioscopy

Sirolimus-eluting stents (SES) are now commonly used for percutaneous coronary intervention (PCI) because they dramatically reduce the rates of restenosis and target lesion revascularization, even in small vessels and long lesions as compared with bare-metal stent. The unresolved issue about SES use is the possibility of late stent thrombosis. Late stent thrombosis is a very rare, but serious complication that may result in acute myocardial infarction or sudden cardiac death. However, the mechanism of late stent thrombosis with SES has not been established. We report a patient with very late stent thrombosis 37 months after SES implantation who underwent optical coherence tomography and coronary angioscopy.     

Late restenosis following sirolimus-eluting stent implantation

Despite encouraging results from randomized trials, concerns exist about long-term results of sirolimus-eluting stent implantation. We sought to determine whether in-stent restenosis occurring >1 year ("late") after sirolimus-eluting stent implantation is a real clinical entity. We analyzed data on all sirolimus-eluting stents implanted in our institution before March 2003. During the study period 928 lesions in 433 patients were treated. Angiographic follow-up was performed in 306 patients (70.6%) with 679 lesions (73.2%). Angiography after 1 year was performed only in symptomatic patients. We considered restenosis "early" if it occurred during the first year and late if after 1 year. Late restenosis required demonstration of a widely patent stent at 6 to 9 months, with repeat angiography after 1 year demonstrating restenosis. Restenosis occurred in 160 lesions overall (23.5%). Of the 31 (4.6%) that were documented after 1 year, 13 were excluded from analysis due to absence of 6- to 9-month angiography; the remaining 18 (2.6%, 1.7 to 4.2) fulfilled our criteria for late restenosis (median time of documentation 607 days, interquartile range 511 to 923). In conclusion, late restenosis is an infrequent but real entity; its existence implies we should not discount the possibility of restenosis as the cause of symptoms that develop >1 year after sirolimus-eluting stent implantation.     

血管内超声评价雷帕霉素洗脱支架再狭窄及早期血栓形成

Objective To identify underlying mechanical risk factors of that developed in-stent restenosis (ISR) or early stent thrombosis in sirolimus-eluting stent (SES)-treated lesions using intravascular ultrasound (IVUS). Methods IVUS were performed in 60 (ISR, n = 43; early stent thrombosis, n = 17) patients (event group) and in 34 patients without ISR and early stent thrombosis (noevent group) underwent SES implantations. Results Compared with the no-event group, minimum stent area [MSA, (4.6±1.6) mm2 vs. (5.8±1.6) mm2, P ＜0.01], minimum stent diameter [(2.2±0.5) mm vs. (2.5±0.4) mm, P＜0.01],andstentexpansion[(69.2±20.7)% vs. (80.6±17.2)%,P＜ 0.01] were significantly smaller, and longitudinal stent symmetry index (MSA/maximum stent area, 2.0±0.6 vs. 1.7±0.6, P ＜ 0.05) was significantly larger in the event group. Incidence of MSA ＜ 4.0 mm2(43.3% vs. 14.7%, P ＜0.01) and stent expansion ＜60% (40.7% vs. 11.8%, P ＜0.01) were more frequent in the event group than that in no-event group. Furthermore, proximal residual plaque burden was significantly higher compared to the no-event group [(49.0±15.5) % vs. (38.4±17.6) %, P ＜ 0.01]. Independent predictors of post SES 1SR or early thrombosis were MSA (OR:0.7, 95% CI:0.5-0.8, P ＜ 0.01) and proximal residual plaque burden (OR:280.7, 95% CI: 17.2-40 583.6, P ＜ 0.01). Conclusion Smaller MSA and higher proximal residual plaque burden are independent predictors of ISR or early thrombosis post SES implantations.