Mechanisms of very late drug-eluting stent thrombosis assessed by optical coherence tomography
Selected in Circulation by G.G. Stefanini
Taniwaki M, Radu MD, Zaugg S, Amabile N, Garcia-Garcia HM, Yamaji K, Jørgensen E, Kelbæk H, Pilgrim T, Caussin C, Zanchin T, Veugeois A, Abildgaard U, Jüni P, Cook S, Koskinas KC, Windecker S, Räber L
Circulation. 2016 Feb 16;133(7):650-60
LinkAccess the abstract
What is known
Although infrequent with the use of contemporary drug-eluting stents (DES), stent thrombosis remains an important concern since it leads to myocardial infarction and death in up to 80%. Early stent thrombosis is mainly related to procedural variables. Whereas, the pathophysiologic mechanisms underlying very late stent thrombosis (VLST) after implantation of drug-eluting-stents (DES) are incompletely understood.
Aim of the study
To assess the mechanisms underlying VLST as assessed by optical coherence tomography (OCT) in the largest cohort of patients treated with DES (early and newer generations).
- 64 patients with definite VLST were evaluated with OCT in the acute setting in the context of an international multicenter (4 centers) OCT registry between 2010 and 2014.
- OCT pullbacks were performed after restoration of flow
- 38 early- and 20 newer-generation DES were analyzed
- VLST occurred at a median of 4.7 years (IQ range: 3.1–7.5 years)
- At OCT analysis, an underlying cause was identified in 98% of VLST cases.
- The most frequent findings were strut malapposition (34.5%), neoatherosclerosis (27.6%), uncovered struts (12.1%), and stent underexpansion (6.9%).
The results of this analysis indicate that:
- OCT is able to identify the underlying cause of VLST in the majority of cases.
- The combination of multiple mechanisms of VLST within the same lesion was observed more frequently (55%) than the presence of a single cause (43%).
- Malapposition combined with uncovered struts was the most common trigger of VLST (29%), followed by neoatherosclerosis (26%).
- The longitudinal extension of malapposed and uncovered struts is related to the occurrence of VSLT.
- The association of malapposition and uncovered stent struts with VLST as well as the frequency of neoatherosclerosis were consistent in early- and new-generation DES, suggesting that VLST mechanisms are comparable between different generations of DES.