International Journal of Cardiology 187 (2015) 141–143
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
The butler did it! A very late stent thrombosis of TAXUS evaluated with Optical Coherence Tomography Mario Iannaccone ⁎, Fabrizio D'Ascenzo, Antonio Montefusco, Claudio Moretti, Fiorenzo Gaita Città della Scienza e della Salute, Turin, Italy
a r t i c l e
i n f o
Article history: Received 3 March 2015 Accepted 19 March 2015 Available online 20 March 2015 Keywords: Optical Coherence Tomography Very late stent thrombosis TAXUS
A 64 year old male smoker, obese, diabetic non-insulin dependent, and with dyslipidemia, presented to our Emergency Department for new onset typical chest pain and EKG signs of an acute anterior ST elevation myocardial infarction. He had a history of a percutaneous coronary interventions to his three vessels with stents TAXUS in 2006 when he presented with stable angina. He performed dual antiplatelet therapy (DAT) for six months, then he assumed aspirin alone. During the successive follow-up the ischemic burden of the patient was explored with the ergometric test each two years, which proved negative for inducible ischemia. After 1 h from chest pain onset, radial coronary angiography showed the left anterior descending (LAD) occlusion due to intrastent thrombosis (ST) (Fig. 1). The lesion was treated with thrombus aspiration using an Export catheter with rapid restoration of TIMI 3 flow and no evidence of residual angiographic stenosis. Optical Coherence tomography (OCT) (LightLab Imaging, St. Jude, Inc., Westford, Massachusetts, USA) imaging was performed, using automatic injection of contrast to obtain a blood-free zone environment, on the LAD stent to identify a predisposing factor to the stent thrombosis. In the proximal tract of the stent a disrupted plaque with superimposed thrombi and acquired struts malapposition was noted. In the remaining stent segment diffuse areas of neoatherosclerosis with fibrocalcific plaques and microvessels were evident with a minimal lumen area of 3.8 mm2. A very late stent thrombosis (VLST) secondary to the disruption of a lipid rich neoatherosclerotic plaque was postulated as a mechanism for his acute myocardial infarction. Due to the absence of significant obstructive lesions within the coronary segment no subsequent intervention was ⁎ Corresponding author at: Città della Scienza e della Salute, Corso Bramante 10100, Turin, Italy. E-mail address: [email protected] (M. Iannaccone).
http://dx.doi.org/10.1016/j.ijcard.2015.03.264 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
performed. The patient was discharged from our division after 5 days treated with optimal medical therapy including aspirin and prasugrel. To assess the healing process an angiographic control was scheduled after three months showing neither intrastent restenosis nor de novo lesions. The lesion on LAD revealed an almost completed resolution of the lost tissue with no evidence of malapposed struts and the persistence of some uncovered struts at the inflow tract (Fig. 2). The patient was discharged with the same pharmacologic therapy and programmed clinical examinations at follow-up. We read with interest the systematic review recently published by Franck et al. [1] about very late stent thrombosis (VLST) in the first generation DES. Doctor Franck concludes that “The medical management of patients with first-generation DES is likely to be heavily influenced by physician preference regarding the indefinite or limited continuation of DAPT”. Very late stent thrombosis is a rare complication and the TAXUS [2] registry reports up to five years after implantation a rate of VLST of 0.4%. Mechanisms determining this unlucky event are not well known. Pathologic studies have suggested delayed re-endothelialization as an important substrate [3]. More recently, the development of atherosclerotic changes within the neointima (neoatherosclerosis) has been identified as another important mechanism of very late ST [4]. In these patients, as underlined by several studies [5], many predisposing factors to ST, due to both patient characteristics (diabetes, previous PCI with first generation drug eluting stent) and lesions themselves (multi-vessel disease, lesion length), were present, without an increased bleeding risk. Moreover DAT was discontinued after 6 months from stent implantation and aspirin alone was assumed. In our experience, the complete tissue recovery and the resolution of the malapposed struts across all the lesions in the second procedure underline a late acquired malapposition due to an ulcerated plaque rupture (neoatherosclerosis). Moreover, coronary stenting was not performed because of the evidence of lesion healing and a subcritical lumen area. Furthermore as suggested by doctor Frank [1], in a specific subset of patients with intrastent restenosis, with low bleeding risk, despite the recent evidences [6] that do not demonstrate a net benefit, long term continuation of DAPT should be evaluated. Conflict of interest The authors report no relationships that could be construed as a conflict of interest.
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M. Iannaccone et al. / International Journal of Cardiology 187 (2015) 141–143
Fig. 1. First coronary angiography and Optical Coherence Tomography.
Fig. 2. 3 month follow-up Optical Coherence Tomography.
M. Iannaccone et al. / International Journal of Cardiology 187 (2015) 141–143
References [1] C. Franck, M.J. Eisenberg, T. Dourian, S.M. Grandi, K.B. Filion, Very late stent thrombosis in patients with first-generation drug-eluting stents: a systematic review of reported cases, Int. J. Cardiol. 177 (3) (Dec 20 2014) 1056–1058, http://dx.doi.org/10.1016/j.ijcard.2014. 11.030 (Epub 2014 Nov 5. PubMed PMID: 25465837). [2] S.G. Ellis, G.W. Stone, D.A. Cox, J. Hermiller, C. O'Shaughnessy, T. Mann, M. Turco, R. Caputo, P.J. Bergin, T.S. Bowman, D.S. Baim, TAXUS IV Investigators, Long-term safety and efficacy with paclitaxel-eluting stents: 5-year final results of the TAXUS IV clinical trial (TAXUS IV-SR: Treatment of De Novo Coronary Disease Using a Single PaclitaxelEluting Stent), JACC Cardiovasc. Interv. 2 (12) (Dec 2009) 1248–1259, http://dx.doi. org/10.1016/j.jcin.2009.10.003 (PubMed PMID: 20129552). [3] M. Joner, A.V. Finn, A. Farb, et al., Pathology of drug-eluting stents in humans. Delayed healing and late thrombotic risk, J. Am. Coll. Cardiol. 48 (1) (2006) 193–202. [4] G. Nakazawa, F. Otsuka, M. Nakano, M. Vorpahl, S.K. Yazdani, E. Ladich, F.D. Kolodgie, A.V. Finn, R. Virmani, The pathology of neoatherosclerosis in human coronary implants
143
bare-metal and drug-eluting stents, J. Am. Coll. Cardiol. 57 (11) (Mar 15 2011) 1314–1322, http://dx.doi.org/10.1016/j.jacc.2011.01.011 (PubMed PMID: 21376502; PubMed Central PMCID: PMC3093310). [5] F. D'Ascenzo, M. Bollati, F. Clementi, D. Castagno, B. Lagerqvist, J.M. de la Torre Hernandez, J.M. ten Berg, B.R. Brodie, P. Urban, L.O. Jensen, G. Sardi, R. Waksman, J.M. Lasala, S. Schulz, G.W. Stone, F. Airoldi, A. Colombo, G. Lemesle, R.J. Applegate, P. Buonamici, A.J. Kirtane, A. Undas, I. Sheiban, F. Gaita, G. Sangiorgi, M.G. Modena, G. Frati, G. Biondi-Zoccai, Incidence and predictors of coronary stent thrombosis: evidence from an international collaborative meta-analysis including 30 studies, 221,066 patients, and 4276 thromboses, Int. J. Cardiol. 167 (2) (Jul 31 2013) 575–584. [6] F. D'Ascenzo, F. Colombo, U. Barbero, C. Moretti, P. Omedè, M.J. Reed, G. Tarantini, G. Frati, J.J. Di Nicolantonio, G. Biondi Zoccai, F. Gaita, Discontinuation of dual antiplatelet therapy over 12 months after acute coronary syndromes increases risk for adverse events in patients treated with percutaneous coronary intervention: systematic review and meta-analysis, J. Interv. Cardiol. 27 (3) (Jun 2014) 233–241.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
The butler did it! A very late stent thrombosis of TAXUS evaluated with Optical Coherence Tomography Mario Iannaccone ⁎, Fabrizio D'Ascenzo, Antonio Montefusco, Claudio Moretti, Fiorenzo Gaita Città della Scienza e della Salute, Turin, Italy
a r t i c l e
i n f o
Article history: Received 3 March 2015 Accepted 19 March 2015 Available online 20 March 2015 Keywords: Optical Coherence Tomography Very late stent thrombosis TAXUS
A 64 year old male smoker, obese, diabetic non-insulin dependent, and with dyslipidemia, presented to our Emergency Department for new onset typical chest pain and EKG signs of an acute anterior ST elevation myocardial infarction. He had a history of a percutaneous coronary interventions to his three vessels with stents TAXUS in 2006 when he presented with stable angina. He performed dual antiplatelet therapy (DAT) for six months, then he assumed aspirin alone. During the successive follow-up the ischemic burden of the patient was explored with the ergometric test each two years, which proved negative for inducible ischemia. After 1 h from chest pain onset, radial coronary angiography showed the left anterior descending (LAD) occlusion due to intrastent thrombosis (ST) (Fig. 1). The lesion was treated with thrombus aspiration using an Export catheter with rapid restoration of TIMI 3 flow and no evidence of residual angiographic stenosis. Optical Coherence tomography (OCT) (LightLab Imaging, St. Jude, Inc., Westford, Massachusetts, USA) imaging was performed, using automatic injection of contrast to obtain a blood-free zone environment, on the LAD stent to identify a predisposing factor to the stent thrombosis. In the proximal tract of the stent a disrupted plaque with superimposed thrombi and acquired struts malapposition was noted. In the remaining stent segment diffuse areas of neoatherosclerosis with fibrocalcific plaques and microvessels were evident with a minimal lumen area of 3.8 mm2. A very late stent thrombosis (VLST) secondary to the disruption of a lipid rich neoatherosclerotic plaque was postulated as a mechanism for his acute myocardial infarction. Due to the absence of significant obstructive lesions within the coronary segment no subsequent intervention was ⁎ Corresponding author at: Città della Scienza e della Salute, Corso Bramante 10100, Turin, Italy. E-mail address: [email protected] (M. Iannaccone).
http://dx.doi.org/10.1016/j.ijcard.2015.03.264 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
performed. The patient was discharged from our division after 5 days treated with optimal medical therapy including aspirin and prasugrel. To assess the healing process an angiographic control was scheduled after three months showing neither intrastent restenosis nor de novo lesions. The lesion on LAD revealed an almost completed resolution of the lost tissue with no evidence of malapposed struts and the persistence of some uncovered struts at the inflow tract (Fig. 2). The patient was discharged with the same pharmacologic therapy and programmed clinical examinations at follow-up. We read with interest the systematic review recently published by Franck et al. [1] about very late stent thrombosis (VLST) in the first generation DES. Doctor Franck concludes that “The medical management of patients with first-generation DES is likely to be heavily influenced by physician preference regarding the indefinite or limited continuation of DAPT”. Very late stent thrombosis is a rare complication and the TAXUS [2] registry reports up to five years after implantation a rate of VLST of 0.4%. Mechanisms determining this unlucky event are not well known. Pathologic studies have suggested delayed re-endothelialization as an important substrate [3]. More recently, the development of atherosclerotic changes within the neointima (neoatherosclerosis) has been identified as another important mechanism of very late ST [4]. In these patients, as underlined by several studies [5], many predisposing factors to ST, due to both patient characteristics (diabetes, previous PCI with first generation drug eluting stent) and lesions themselves (multi-vessel disease, lesion length), were present, without an increased bleeding risk. Moreover DAT was discontinued after 6 months from stent implantation and aspirin alone was assumed. In our experience, the complete tissue recovery and the resolution of the malapposed struts across all the lesions in the second procedure underline a late acquired malapposition due to an ulcerated plaque rupture (neoatherosclerosis). Moreover, coronary stenting was not performed because of the evidence of lesion healing and a subcritical lumen area. Furthermore as suggested by doctor Frank [1], in a specific subset of patients with intrastent restenosis, with low bleeding risk, despite the recent evidences [6] that do not demonstrate a net benefit, long term continuation of DAPT should be evaluated. Conflict of interest The authors report no relationships that could be construed as a conflict of interest.
142
M. Iannaccone et al. / International Journal of Cardiology 187 (2015) 141–143
Fig. 1. First coronary angiography and Optical Coherence Tomography.
Fig. 2. 3 month follow-up Optical Coherence Tomography.
M. Iannaccone et al. / International Journal of Cardiology 187 (2015) 141–143
References [1] C. Franck, M.J. Eisenberg, T. Dourian, S.M. Grandi, K.B. Filion, Very late stent thrombosis in patients with first-generation drug-eluting stents: a systematic review of reported cases, Int. J. Cardiol. 177 (3) (Dec 20 2014) 1056–1058, http://dx.doi.org/10.1016/j.ijcard.2014. 11.030 (Epub 2014 Nov 5. PubMed PMID: 25465837). [2] S.G. Ellis, G.W. Stone, D.A. Cox, J. Hermiller, C. O'Shaughnessy, T. Mann, M. Turco, R. Caputo, P.J. Bergin, T.S. Bowman, D.S. Baim, TAXUS IV Investigators, Long-term safety and efficacy with paclitaxel-eluting stents: 5-year final results of the TAXUS IV clinical trial (TAXUS IV-SR: Treatment of De Novo Coronary Disease Using a Single PaclitaxelEluting Stent), JACC Cardiovasc. Interv. 2 (12) (Dec 2009) 1248–1259, http://dx.doi. org/10.1016/j.jcin.2009.10.003 (PubMed PMID: 20129552). [3] M. Joner, A.V. Finn, A. Farb, et al., Pathology of drug-eluting stents in humans. Delayed healing and late thrombotic risk, J. Am. Coll. Cardiol. 48 (1) (2006) 193–202. [4] G. Nakazawa, F. Otsuka, M. Nakano, M. Vorpahl, S.K. Yazdani, E. Ladich, F.D. Kolodgie, A.V. Finn, R. Virmani, The pathology of neoatherosclerosis in human coronary implants
143
bare-metal and drug-eluting stents, J. Am. Coll. Cardiol. 57 (11) (Mar 15 2011) 1314–1322, http://dx.doi.org/10.1016/j.jacc.2011.01.011 (PubMed PMID: 21376502; PubMed Central PMCID: PMC3093310). [5] F. D'Ascenzo, M. Bollati, F. Clementi, D. Castagno, B. Lagerqvist, J.M. de la Torre Hernandez, J.M. ten Berg, B.R. Brodie, P. Urban, L.O. Jensen, G. Sardi, R. Waksman, J.M. Lasala, S. Schulz, G.W. Stone, F. Airoldi, A. Colombo, G. Lemesle, R.J. Applegate, P. Buonamici, A.J. Kirtane, A. Undas, I. Sheiban, F. Gaita, G. Sangiorgi, M.G. Modena, G. Frati, G. Biondi-Zoccai, Incidence and predictors of coronary stent thrombosis: evidence from an international collaborative meta-analysis including 30 studies, 221,066 patients, and 4276 thromboses, Int. J. Cardiol. 167 (2) (Jul 31 2013) 575–584. [6] F. D'Ascenzo, F. Colombo, U. Barbero, C. Moretti, P. Omedè, M.J. Reed, G. Tarantini, G. Frati, J.J. Di Nicolantonio, G. Biondi Zoccai, F. Gaita, Discontinuation of dual antiplatelet therapy over 12 months after acute coronary syndromes increases risk for adverse events in patients treated with percutaneous coronary intervention: systematic review and meta-analysis, J. Interv. Cardiol. 27 (3) (Jun 2014) 233–241.
