𝐒𝐭𝐞𝐧𝐭 𝐓𝐡𝐫𝐨𝐦𝐛𝐨𝐬𝐢𝐬
#CCU_CORONARY
Stent Thrombosis, although rare (occur in <1%
patients within the first year), is one of the most
serious complications following stent placement.
More than 80% of patients who experience
stent thrombosis present with acute MI, and
30-day mortality rates in patients with stent
thrombosis range from 10% to 25%.
As a result, prevention and treatment of
this complication are of utmost importance.
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𝙏𝙝𝙚 𝙢𝙤𝙨𝙩 𝙬𝙞𝙙𝙚𝙡𝙮 𝙪𝙨𝙚𝙙 𝙙𝙚𝙛𝙞𝙣𝙞𝙩𝙞𝙤𝙣 𝙞𝙣𝙫𝙤𝙡𝙫𝙞𝙣𝙜 𝙩𝙝𝙚 𝙘𝙡𝙖𝙨𝙨𝙞𝙛𝙞𝙘𝙖𝙩𝙞𝙤𝙣 𝙖𝙣𝙙 𝙩𝙞𝙢𝙞𝙣𝙜 𝙤𝙛 𝙨𝙩𝙚𝙣𝙩 𝙩𝙝𝙧𝙤𝙢𝙗𝙤𝙨𝙞𝙨 𝙬𝙖𝙨 𝙙𝙚𝙫𝙚𝙡𝙤𝙥𝙚𝙙 𝙗𝙮 𝙩𝙝𝙚 𝘼𝙘𝙖𝙙𝙚𝙢𝙞𝙘 𝙍𝙚𝙨𝙚𝙖𝙧𝙘𝙝 𝘾𝙤𝙣𝙨𝙤𝙧𝙩𝙞𝙪𝙢
𝐃𝐞𝐟𝐢𝐧𝐢𝐭𝐞 stent thrombosis is confirmed by
angiographic or autopsy evidence of thrombus in the setting of an acute coronary syndrome, and
𝐏𝐫𝐨𝐛𝐚𝐛𝐥𝐞 stent thrombosis is defined as
unexplained death within 30 days after stent implantation or acute MI involving the target vessel territory without angiographic confirmation.
𝘼𝙘𝙪𝙩𝙚 𝙩𝙝𝙧𝙤𝙢𝙗𝙤𝙨𝙞𝙨 𝙤𝙘𝙘𝙪𝙧𝙨 𝙬𝙞𝙩𝙝𝙞𝙣 24 𝙝𝙤𝙪𝙧𝙨
(excluding intraprocedural events within
the catheterization laboratory),
𝙎𝙪𝙗𝙖𝙘𝙪𝙩𝙚 𝙗𝙚𝙩𝙬𝙚𝙚𝙣 1 𝙙𝙖𝙮 𝙖𝙣𝙙 30 𝙙𝙖𝙮𝙨,
𝙀𝙖𝙧𝙡𝙮 𝙬𝙞𝙩𝙝𝙞𝙣 30 𝙙𝙖𝙮𝙨
(counting both acute and subacute events),
𝙇𝙖𝙩𝙚 𝙗𝙚𝙩𝙬𝙚𝙚𝙣 30 𝙙𝙖𝙮𝙨 𝙖𝙣𝙙 1 𝙮𝙚𝙖𝙧, and
𝙑𝙚𝙧𝙮 𝙇𝙖𝙩𝙚 𝙖𝙛𝙩𝙚𝙧 1 𝙮𝙚𝙖𝙧.
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𝙏𝙝𝙧𝙤𝙢𝙗𝙤𝙩𝙞𝙘 𝙤𝙘𝙘𝙡𝙪𝙨𝙞𝙤𝙣 is classified as :-
▫️ 𝙋𝙧𝙞𝙢𝙖𝙧𝙮 if it is directly related to the stent implantation
▫️ 𝙎𝙚𝙘𝙤𝙣𝙙𝙖𝙧𝙮 if it occurs at the stent site after
a subsequent intervention to the target lesion.
Risk Factors Stent thrombosis can occur as
a result of many reasons, including •••
𝙋𝙖𝙩𝙞𝙚𝙣𝙩-𝙧𝙚𝙡𝙖𝙩𝙚𝙙 𝙛𝙖𝙘𝙩𝙤𝙧𝙨
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Patients who 𝙥𝙧𝙚𝙨𝙚𝙣𝙩 𝙬𝙞𝙩𝙝 thrombotic ACS, Smokers, and Diabetes and/or chronic kidney as well as severely depressed left ventricular function
are all more prone to stent thrombosis.
High residual 𝙥𝙡𝙖𝙩𝙚𝙡𝙚𝙩 𝙧𝙚𝙖𝙘𝙩𝙞𝙫𝙞𝙩𝙮 after treatment,
which can be seen in patients with genetic mutations in the enzyme responsible for
converting clopidogrel to its active metabolite,
has been associated with stent thrombosis.
𝙇𝙚𝙨𝙞𝙤𝙣 𝙛𝙖𝙘𝙩𝙤𝙧𝙨 that increase risk of thrombosis include diffuse disease with long stented segments, small vessels, bifurcation disease, and significant inflow or outflow lesions proximal or distal to the stent.
𝙋𝙧𝙤𝙘𝙚𝙙𝙪𝙧𝙖𝙡 𝙛𝙖𝙘𝙩𝙤𝙧𝙨 :
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▫️inadequate stent expansion and/or apposition,
▫️Stent type used (i.e., BMS or DES),
▫️Excessive stent overlap, and
▫️Edge dissections limiting inflow or outflow.
▫️Strut fracture linked to +Risk of thrombosis.
The thicker struts of earlier generation BMS and DES systems have been associated with increased risk of stent thrombosis, and this may have implications in the thrombosis risk of first-generation bioabsorbable scaffolds.
In addition, the polymers used in certain first-generation DES systems may be inherently throm-bogenic and/or prone to mechanical deformation after implantation, serving as a nidus for thombus formation.
𝙋𝙤𝙨𝙩𝙥𝙧𝙤𝙘𝙚𝙙𝙪𝙧𝙖𝙡 𝙧𝙞𝙨𝙠 𝙛𝙖𝙘𝙩𝙤𝙧𝙨:-
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▫️ 𝐃iscontinuation Early of dual-antiplatelet
(although the ideal length of treatment
varies by the specific stent system),
▫️ 𝐃elayed re-endothelialization of stent struts
in DES systems due to antiproliferative agent
▫️ 𝐃evelopment of neoatherosclerosis within
the stent leading to plaque rupture.
Specific strategies aimed at reducing the occurrence of stent thrombosis are shown image👇
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𝐓𝐫𝐞𝐚𝐭𝐦𝐞𝐧𝐭 𝐨𝐟 𝐬𝐭𝐞𝐧𝐭 𝐭𝐡𝐫𝐨𝐦𝐛𝐨𝐬𝐢𝐬,
especially when presenting as acute MI,
is almost always 𝙀𝙢𝙚𝙧𝙜𝙚𝙣𝙩 𝙋𝘾𝙄.
▪️Options for restoring perfusion include :
▫️ 𝙏𝙝𝙧𝙤𝙢𝙗𝙚𝙘𝙩𝙤𝙢𝙮 either aspiration or mechanical