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?

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Failing stents: thrombosis vs restenosis

Schuchman, New Engl J Med 2006

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Stent thrombosis in the medical literature

Google Scholar searched for “stent AND thrombosis” on 8 June 2010

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 History of stent thrombosis

IMPACT OF DUAL ANTIPLATELET THERAPY AND HIGH PRESSURE DILATION

18 16
16
Acute and subacute stent

14
12
thrombosis (%)

10
8
6
4
3,5
1,4 0,8 1,5 0,9 1,6 1
2 0,6
0
PS - 1991 STRESS - Colombo - ISAR - STARS - Moussa - Cutlip - Wenaweser Moreno -
1995 1995 1996 1997 1999 2001 - 2005 2006

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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

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Timing of stent thrombosis

Type Occurrence* Incidence

Acute ≤1 day +
Subacute 2-30 days +++
Late 2-12 months ++
Very late >1 year ++

*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 LESION
FACTORS 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

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 Predicting thrombosis according to stent length

Moreno et al, J Am Coll Cardiol 2005

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What about late stent thrombosis?

McFadden et al, Lancet 2004

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Impact of antiplatelet therapy discontinuation

Kimura et al, Circulation 2009

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 Impact of antiplatelet therapy intensity

30-day results of the CURRENT-OASIS 7 Trial

Clopidogrel Clopidogrel
P
600+150 mg 300+75 mg
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
3.0% 3.7% 0.008
thrombosis
Cardiovascular death,
3.9% 4.5% 0.036
myocardial infarction, or stroke

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

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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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 Timing and incidence of stent thrombosis

Early stent Late stent Very late stent

Stents
thrombosis thrombosis 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 0.4% vs 0 0.3% vs 0.6% 0.3% vs 1.0%

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

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 Incidence of stent thrombosis in Sweden

Lagerqvist et al, Circulation Int 2009

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 Outlook after stent thrombosis

Van Werkum et al, Circulation 2009

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 Impact of BMS thrombosis

Cutlip et al, Circulation 2001

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 Impact of definite DES thrombosis

Kuchulakanti et al, Circulation 2006

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 Impact of definite or probable DES thrombosis

Mauri et al, New Engl J Med 2007

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 More on impact of DES thrombosis

Daemen et al, Lancet 2007

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 Stent thrombosis in further perspective

Daemen et al, Lancet 2007

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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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