STENT THROMBOSIS:
WHICH IMPACT IN REAL
CLINICAL PRACTICE?
Giuseppe Biondi Zoccai
Divisione di Cardiologia, Università di Torino
Ospedale S. Giovanni Battista “Molinette” Torino
gbiondizoccai@gmail.com
Learning goals
• What is stent thrombosis?
• Can I predict stent thrombosis?
• What is the real impact of stent thrombosis?
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Learning goals
• What is stent thrombosis?
• Can I predict stent thrombosis?
• What is the real impact of stent thrombosis?
3
Failing stents: thrombosis vs restenosis
Schuchman, New Engl J Med 2006
4
Stent thrombosis in the medical literature
Google Scholar searched for “stent AND thrombosis” on 8 June 2010
5
History of stent thrombosis
Acute and subacute stent
thrombosis (%)
IMPACT OF DUAL ANTIPLATELET THERAPY AND HIGH PRESSURE DILATION
18
16
14
12
10
8
6
4
2
0
16
3,5
1,4
PS - 1991
STRESS - Colombo 1995
1995
0,8
0,6
ISAR 1996
STARS 1997
1,5
Moussa 1999
0,9
Cutlip 2001
1,6
1
Wenaweser Moreno 2006
- 2005
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Definition of stent thrombosis
• Acute occlusion of a previously patent stent
• It is a clinical syndrome (presents with acute
coronary syndrome or sudden death – if silent
cannot be defined stent thrombosis)
• It is not due to new plaque rupture at distant site
• There was no severe restenosis with final occlusion
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Academic Research Consortium definitions
•Definite:
• Clinical syndrome (ACS or AMI)
• and angiographic evidence of thrombus or occlusion
• or pathologic evidence of acute thrombosis
•Probable:
• Unexplained death < 30 days
• or target vessel AMI without angiographic confirmation of
thrombosis or other identified culprit lesion
•Possible:
• Unexplained death after 30 days
Cutlip et al, Circulation 2007
8
Timing of stent thrombosis
Type
Acute
Subacute
Late
Very late
Occurrence*
≤1 day
2-30 days
2-12 months
>1 year
Incidence
+
+++
++
++
*after PCI
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Learning goals
• What is stent thrombosis?
• Can I predict stent thrombosis?
• What is the real impact of stent thrombosis?
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Mechanisms of thrombosis: Virchow's triad
BLOOD
FLOW
VESSEL
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Mechanisms of stent thrombosis
PATIENT
FACTORS
LESION
FACTORS
PROCEDURAL &
MEDICAL RX
FACTORS
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Genetic variability in risk of stent thrombosis
Mega et al, New Engl J Med 2009
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Predicting thrombosis according to diabetes
Machecourt et al, J Am Coll Cardiol 2009
14
Predicting thrombosis according to stent length
Moreno et al, J Am Coll Cardiol 2005
15
What about late stent thrombosis?
€
McFadden et al, Lancet 2004
16
Impact of antiplatelet therapy discontinuation
Kimura et al, Circulation 2009
17
Impact of antiplatelet therapy intensity
30-day results of the CURRENT-OASIS 7 Trial
Clopidogrel
600+150 mg
Clopidogrel
300+75 mg
P
Definite stent thrombosis
0.7%
1.2%
0.002
Myocardial infarction
2.0%
2.6%
0.012
Stroke
0.4%
0.4%
0.59
Cardiovascular death
1.9%
1.9%
0.68
Myocardial infarction or stent
thrombosis
3.0%
3.7%
0.008
Cardiovascular death,
myocardial infarction, or stroke
3.9%
4.5%
0.036
Mehta et al, ESC 2009
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Predictors of drug-eluting stent thrombosis
Iakovou et al, JAMA 2005
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Predictors of stent thrombosis after ACS
Van Werkum et al, J Am Coll Cardiol 2009
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Any synthesis possible?
Capodanno et al, Clin Res Cardiol 2009
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Any synthesis possible?
Capodanno et al, Clin Res Cardiol 2009
22
Learning goals
• What is stent thrombosis?
• Can I predict stent thrombosis?
• What is the real impact of stent thrombosis?
23
Timing and incidence of stent thrombosis
Stents
Early stent
thrombosis
Late stent
thrombosis
Very late stent
thrombosis
SES vs BMS1 0.5% vs 0.3% 0.1% vs 1.0%
0.9% vs 0.4%
PES vs BMS1 0.5% vs 0.5% 0.4% vs 0.3%
0.9% vs 0.6%
ZES vs BMS2 0.3% vs 1.2% 0.3% vs 0.1%
0.1% vs 0.1%
EES vs PES3
0.3% vs 1.0%
0.4% vs 0
0.3% vs 0.6%
1Mauri
et al, New Engl J Med 2007
2Leon, TCT 2008
3Stone et al, Circulation 2009
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Incidence of stent thrombosis in Bern &
Rotterdam
Daemen et al, Lancet 2007
25
Incidence of stent thrombosis in Sweden
Lagerqvist et al, Circulation Int 2009
26
Outlook after stent thrombosis
Van Werkum et al, Circulation 2009
27
Impact of BMS thrombosis
Cutlip et al, Circulation 2001
28
Impact of definite DES thrombosis
Kuchulakanti et al, Circulation 2006
29
Impact of definite or probable DES thrombosis
Mauri et al, New Engl J Med 2007
30
More on impact of DES thrombosis
Daemen et al, Lancet 2007
31
Stent thrombosis in further perspective
Daemen et al, Lancet 2007
32
Take home messages
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Take home messages
• Stent thrombosis is a clinically important event,
causing often death or myocardial infarction in those
experiencing it
• Stent thrombosis is however rare, but it can be
predicted by patient and lesion factors, and
modulated by procedural, pharmacologic and other
treatment decisions
• Thus, when addressing the issue of stent
thrombosis, it is crucial to individualize management
strategies in order to maximize benefits and
minimize risks
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Thank you for your attention
For any correspondence:
gbiondizoccai@gmail.com
For these and further slides on these topics
feel free to visit the metcardio.org website:
http://www.metcardio.org/slides.html
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