Stent thrombosis: How to manage itStent thrombosis: How to manage it

Dr Philip MacCarthy BSc PhD FRCPDr Philip MacCarthy BSc PhD FRCP

Consultant CardiologistConsultant Cardiologist

King’s College Hospital, London, UK.King’s College Hospital, London, UK.

ACI 2011 Weds 26th Jan

NO CONFLICT OF INTEREST TO DECLARE

A Step-wise practical guideA Step-wise practical guide

Background facts:Background facts:

May occur a long time after PCIMay occur a long time after PCI

Occurs with BMS as well as DESOccurs with BMS as well as DES

Often associated with alterations in DAPTOften associated with alterations in DAPT

Has a poor outcomeHas a poor outcome

The poor outcome of stent The poor outcome of stent thrombosisthrombosis

Kimura et al RESTART Circulation. 2010 Jul 6;122(1):52-61

Step 1:Step 1: Get the diagnosis right Get the diagnosis right

Usually presents with ST segment elevation MIUsually presents with ST segment elevation MI

History/details of previous PCI often lackingHistory/details of previous PCI often lacking

Should be considered even if stenting is many Should be considered even if stenting is many years ago or BMS usedyears ago or BMS used

4yr Drug-eluting stent thrombosis4yr Drug-eluting stent thrombosis

Before June 2006 Nov 2010

Step 1:Step 1: Get the diagnosis right Get the diagnosis right

High index of suspicion when DAPT interrupted High index of suspicion when DAPT interrupted

Kimura et al RESTART Circulation. 2010 Jul 6;122(1):52-61

Outcome just as bad with BMSOutcome just as bad with BMS

Burzotta et al, Eur Heart J 2008;29:3011-21

n=55

n=43

Step 2:Step 2: Adjunctive pharmacology Adjunctive pharmacology

Lack of evidence in this specific populationLack of evidence in this specific population Assume a moderate/high thrombus burdenAssume a moderate/high thrombus burden Oral:Oral:

Prasugrel most appropriatePrasugrel most appropriate IV:IV:

Reopro probably most appropriate (no data) - Reopro probably most appropriate (no data) - 'upstream' preferable'upstream' preferable

Wt-adjusted UFHWt-adjusted UFH Bivalirudin reasonable alternativeBivalirudin reasonable alternative

Evidence for GPIIb/IIIaEvidence for GPIIb/IIIa

Wenewesar Eur Heart J 2005;26:1180

Step 3:Step 3: A careful diagnostic A careful diagnostic angiogramangiogram

Step 3:Step 3: A careful diagnostic A careful diagnostic angiogramangiogram

Radial access makes senseRadial access makes sense

Thrombus often propagates proximallyThrombus often propagates proximally

Consider new disease adjacent to stentConsider new disease adjacent to stent

'Stent boost' feature - useful for stent edges'Stent boost' feature - useful for stent edges

Step 4:Step 4: Wiring Wiring

Often surprisingly difficultOften surprisingly difficult

Easy to 'pick up a strut' - consider if a small Easy to 'pick up a strut' - consider if a small balloon will not easily pass through the stent - balloon will not easily pass through the stent - re-wire if any doubtre-wire if any doubt

Soft-tipped wire 'on a loop'Soft-tipped wire 'on a loop'

Can use support wire if proximal vessel very Can use support wire if proximal vessel very tortuous (esp. if thrombectomy/IVUS planned)tortuous (esp. if thrombectomy/IVUS planned)

Step 5:Step 5: Thrombectomy Thrombectomy

Should always try to perform thrombectomy - if Should always try to perform thrombectomy - if possible before other instrumentationpossible before other instrumentation

Smaller catheter with stylet often easier (eg. Smaller catheter with stylet often easier (eg. Pronto LP). Bulky thrombectomy catheters get Pronto LP). Bulky thrombectomy catheters get stuck on the stentstuck on the stent

Can use thrombectomy catheter to administer ic. Can use thrombectomy catheter to administer ic. adenosine if slow/no re-flowadenosine if slow/no re-flow

Most try to use thrombectomyMost try to use thrombectomy

Kimura et al RESTART Circulation. 2010 Jul 6;122(1):52-61

Step 6:Step 6: Adjunctive imaging Adjunctive imaging Mandatory (even in the middle of the night!)Mandatory (even in the middle of the night!) IVUS:IVUS:

Stent under-expansionStent under-expansion True vessel sizeTrue vessel size Areas of calcificationAreas of calcification Disease at in/out-flow of stentDisease at in/out-flow of stent Post-interventional resultPost-interventional result

OCT:OCT: Strut malappositionStrut malapposition

IVUS - ThrombusIVUS - Thrombus

IVUS - intraluminal anatomyIVUS - intraluminal anatomy

Distal intimal dissectionMalapposition of proximal stent

OCT imagingOCT imaging

Ozaki et al Eur Heart J (2010) 31 (12): 1470-1476. Matsumoto et al Eur Heart J (2007) 28 (8): 961-967.

Step 7:Step 7: Re-intervention Re-intervention

Depends on what has caused the stent thrombosisDepends on what has caused the stent thrombosis

Stent strut malappositionStent strut malapposition

IVUS-guided NC balloonIVUS-guided NC balloon to high pressure to high pressure

Cook et al Circulation 2007;115:2426

Step 7:Step 7: Re-intervention Re-intervention

Depends on what has caused the stent thrombosisDepends on what has caused the stent thrombosis

Stent strut malappositionStent strut malapposition

IVUS-guided NC balloon to high pressureIVUS-guided NC balloon to high pressure

No mechanical problem - eg Inappropriate DAPT cessation - No mechanical problem - eg Inappropriate DAPT cessation -

POBA with semi-compliant balloon for thrombus (post-POBA with semi-compliant balloon for thrombus (post-thrombectomy)thrombectomy)

In-flow/out-flow diseaseIn-flow/out-flow disease

Re-stenting - caution with DES if problems with DAPT Re-stenting - caution with DES if problems with DAPT compliancecompliance

Try to avoid putting more metalwork in if possibleTry to avoid putting more metalwork in if possible

Step 7:Step 7: Re-intervention Re-intervention

Burzotta et al, Eur Heart J 2008;29:3011-21

Burzotta et al, Eur Heart J 2008;29:3011-21

ESTROFA J Am Coll Cardiol 2008;51:986-90

Slow flow predicts a poor outcomeSlow flow predicts a poor outcome

Step 7:Step 7: Re-intervention Re-intervention

Burzotta et al, Eur Heart J 2008;29:3011-21

Slow flow predicts a poor Slow flow predicts a poor outcomeoutcome

Step 8:Step 8: Post re-intervention Post re-intervention managementmanagement

Depends on the cause - but consider:Depends on the cause - but consider:

Platelet function testing (eg.VerifyNow)Platelet function testing (eg.VerifyNow)

Prasugrel anywayPrasugrel anyway

1 year for both DES and BMS stent thrombosis1 year for both DES and BMS stent thrombosis

Patient education if compliance an issue Patient education if compliance an issue (Cardiac rehab teams, patient DAPT card etc)(Cardiac rehab teams, patient DAPT card etc)

ConclusionsConclusions

Stent thrombosis carries a high mortality and Stent thrombosis carries a high mortality and needs to be recognised/diagnosed promptlyneeds to be recognised/diagnosed promptly

Appropriate (upstream) pharmacology and Appropriate (upstream) pharmacology and thrombectomy are importantthrombectomy are important

IVUS/OCT vital for a good re-interventionIVUS/OCT vital for a good re-intervention

Try to avoid re-stentingTry to avoid re-stenting

Careful thought about antiplatelet Careful thought about antiplatelet sensitivity/treatment post-stent thrombosissensitivity/treatment post-stent thrombosis

AcknowledgementsAcknowledgements

Jon Byrne for IVUS imagesJon Byrne for IVUS images

Burzotta et al, Eur Heart J 2008;29:3011-21

The poor outcome of stent The poor outcome of stent thrombosisthrombosis

Representative optical coherence tomography-derived cross-sectional image demonstrating thrombus associated with an incompletely apposed stent strut (left panel) as well as

thrombus associated without incompletely apposed stent strut (right panel).

Ozaki Y et al. Eur Heart J 2010;31:1470-1476

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2010. For permissions please email: journals.permissions@oxfordjournals.org

Presentation of stent thrombosisPresentation of stent thrombosis

ESTROFA J Am Coll Cardiol 2008;51:986