stent thrombosis: how to manage it dr philip maccarthy bsc phd frcp consultant cardiologist king’s...
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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: [email protected]
Presentation of stent thrombosisPresentation of stent thrombosis
ESTROFA J Am Coll Cardiol 2008;51:986