treatment of late stent thrombosis
DESCRIPTION
TRANSCRIPT
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DEV PAHLAJANI MD,FACC,FSCAICHIEF OF INTERVENTIONAL CARDIOLOGY,
BREACH CANDY HOSPITAL,MUMBAI
TREATMENT OF LATE AND VERY LATE STENT THROMBOSIS
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DES increased thrombogenicity
• According to the Euro PCR-06 Daily; a 1.2% rate of late stent thrombosis means around 30,000 people were affected, accounting for a 45% mortality rate.
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BMS VS DES –ADVERSE EVENTSIncidences of serious adverse events (Death or MI)
N=870N=878
N=1675 N=1685
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Study Design: BASKET LATE trial
743 patients randomized in the BASKET trial and without an event during the 6 month Clopidogrel phase
Bare metalVISION stents (BMS)
N=244
Drug eluting stents(DES)(pooled paclitaxel and sirolimus DES groups)
n=499
Followed for 1 year off clopidogrel
• Primary Endpoint: Composite cardiac death or nonfatal MI• Other Endpoints: “Thrombosis-related events”
Ref: Pfisterer M et al.ACC 2006
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BASKET LATE Trial
• “For every 100 patients treated with DES,3.3 cases of cardiac death or MI are induced for reduction of 5 cases of TLR”
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BASKET-LATEn = 743, 6 – 18 months
Pfisterer M. JACC 2006
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ARC Proposed Standard Definitions DEFINITE (Angiographic or pathologic confirmation): Angiographic confirmation:
1. TIMI 0 with occlusion originating in or within 5 mm of stent in the presence of a thrombus
2. TIMI flow grade 1, 2, or 3 originating in or within 5 mm of stent in the presence of a thrombus
3. AND 1 of the following criteria < 48 hours:4. New acute onset of ischemic symptoms at rest (typical chest pain
with duration >20 minutes)5. New ischemic ECG changes suggestive of acute ischemia6. Typical rise and fall in cardiac biomarkers
Pathologic confirmation:1. Evidence of recent thrombus within the stent determined at autopsy
or via examination of tissue retrieved following thrombectomy
PROBABLE: 1. Any unexplained death within the first 30 days2. Any MI (related to documented acute ischemia and without another obvious
cause) in the territory of the stent
POSSIBLE: Any unexplained death >30 days
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Definite
Too Narrow
Misses people who have an MI but don’t have an angiogram
Definite
Probable
Possible
Too Broad
Includes natural history events (equal
in both arms) that dilute out true ST
signal*Definite
Probable
Best Balance
Includes MI with or without angio, but
not 1.5%/year natural history deaths
* Worse if you include post TLR events• Restenotic stent can’t really develop ST• Brachytherapy or new DES certainly can• More such events occur in the BMS arm
ARC Definitions of Stent Thrombosis - Gaps
Dr. Don Baim, TCT 2006.
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Thrombosis Can Occur Any Time Post-Stent Implantation
Very Late ST
Late ST
SAT
Acute ST
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Time Frame Classification
30 days
90 days
365 days
Very Late> 1 year
0 days
Ear
ly1-
30 d
ays
Acu
te1
Day
Sub-A
cute
2- 3
0 D
ays
Late
>30 days- 1 year
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Occurrence of Stent ThrombosisEVASTENT REGISTRY
JACC 2007, 50, 501
2.5
2.0
1.5
1.0
0.5
0.0Cum
ulati
ve p
roba
bilit
y of
ste
nt
thro
mbo
sis
(%)
Follow-up (days)
0 30 90 180 365
ST+ (n=) 23 26 36 41
ST- (n=) 1692 1679 1669 1664
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Stent ThrombosisP
erc
en
t S
ten
t Th
rom
bosis
Days
Bern-Rotterdam
0
0.5
1
1.5
2
2.5
3
3.5
0 10 30 365 730 1095
1.6
3.22.7
2.51.9
Wenaweser P. et al: EHJ 2005 26 1180-1187.Wenaweser P. et al: ESC 2006.Bern-Rotterdam and HCRI CEC ST definitions both require angiographic confirmation.
Bern TaxusBern BMS
Bern Cypher
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LATE STENT THROMBOSIS
STEMI ACUTE CORONARY SYNDROME
LEFT VENTRICULAR FAILURE CARDIOGENIC SHOCK
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TREATMENT OF LST
MANAGE LIKE PRIMARY PCI
BALLOON DILATATION
SUPPORTIVE MEASURES
IABP IF SHOCK OR LVF
LIBERAL USE OF GPIIB/IIIA BLOCKERS
ASPIRIN AND CLOPIDOGREL IF NOT ON
THROMBUS ASPIRATION
AVOID DES PREFER BMS
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Clinical importance of stent thrombosis
Author/Year BMS/DES ST def Death or MI Death
Cutlip 2001 BMS Angio or clinical
70% 21%
Heller 2001 BMS Angio + AMI 100% 17 %
Iakovou 2005 DES Angio or clinical
45 %
Ong 2005 DES Angio & clinical
100 % 25 %
Kuchulakanti 2006
DES Angio 31 %
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‘Real-world’ outcomes through 1 yearCYPHER (n=2067)
e-CYPHERTAXUS (n=7393)
ARRIVE 1& 2
Stent Thrombosis
P value Stent Thrombosis
P value
Diabetes vs. No Diabetes 1.12 vs. 0.75 0.442.87 vs. 2.03 0.10
2.5 mm vs. >2.5 mm 1.02 vs. 0.73 0.473.06 vs. 1.95 0.03
>28 mm vs. 28 mm 1.90 vs. 0.76 0.224.49 vs. 1.96 <0.0001
Multiple vs. Single stents 1.35 vs. 0.73 0.224.20 vs. 1.43 <0.0001
Multiple vs. Single Vessel 1.16 vs. 0.59 0.043.53 vs. 2.05 0.01
Acute MI vs. Non-AMI 0.67 vs. 0.88 1.003.49 vs. 2.12 0.07
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Incidence of Late stent Thrombosis >30 daysmeta-analysis of 14 randomized clinical trials 6675 pts
Am J of Medicine 2006;119, 1056-1061
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The data suggest that late stent thrombosis occurs at a steady rate during follow-up up to three years, tends to be more frequent with PES than with SES, and can unpredictably occur at any time point despite antiplatelet therapy.
Late stent thrombosis complicating the use of DES seems to be a distinct entity with pathophysiological factors that differ from those of early stent thrombosis.
The data suggest that late stent thrombosis occurs at a steady rate during follow-up up to three years, tends to be more frequent with PES than with SES, and can unpredictably occur at any time point despite antiplatelet therapy.
Late stent thrombosis complicating the use of DES seems to be a distinct entity with pathophysiological factors that differ from those of early stent thrombosis.
Daemen et al. Lancet. 2007 Feb 24; 369: 667 – 78.Daemen et al. Lancet. 2007 Feb 24; 369: 667 – 78.
Bern-Rotterdam Analysis: SummaryBern-Rotterdam Analysis: Summary
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Late Stent Thrombosis—Factors to Consider
Late StentThrombosis
Late IncompleteApposition
DelayedEndothelialization
Discontinuation of Anti-Platelet
TherapyPolymer Hypersensitivity/
Inflammation
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Incidence of Late Stent Thrombosis DESMcFadden E et al. Lancet 2004;364:1519
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Incidence of Thrombosis in 40 autopsy cases of DES
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STENT THROMBOSIS DES
Predictors of late stent thrombosis
2229 consecutive patients at 3 centers
Independent predictors of late ST (>30 days < 9 mo)-premature antiplatelet therapy d/c HR=161-renal failure HR=10.1-bifurcation lesion HR=6.0-diabetes HR=5.8
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Independent Predictors of Late ST
Iakovou I et al JAMA. 2005;293:2126-2130
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Predictors of ST after DES (SES or PES)29/2229 pts (1.3%) at 9.3 ± 5.6 mos
Iakovou et al. JAMA 2005;293:2126-2130
Iakovou I et al JAMA. 2005;293:2126-2130
Multivariate predictors of stent thrombosis:
Renal failure (OR=11.5),Bifurcation (7.2),Prior Brachy Rx (4.2),Diabetes(3.4),And Low LVEF(1.1)
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Late Incomplete AppositionDrug-eluting stent
Dante Pazzanese Experience - 5% at 6 mths (20% had ST)
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Impaired Re-endothelializationPathology findings:
Sirolimus-Eluting stents from different coronary arteries in the same patient (delayed healing)
BMS24 months after
deployment
Cypher16 months after
deployment
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Delayed Arterial healing in DES
Joner, JACC 2006
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Lack of Re-Endothelialization at sites of Thrombosis in DES
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Percentage of Endothelialization in Drug-eluting Stents (DES) VERSUS Bare-metal Stents (BMS)
as a function of Time
J Am Coll Cardiol 2006
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Granulomatous reaction seen in 12.5 and 35% of CYPHER stents implanted for 28 & 90 days in Pig
Coronary Arteries
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Case presented in EURO PCR-05
• A 38 year old female died suddenly, 6 months following Taxus stent placement for AMI
No healing or inflammation observed over the 6 months stent implantation time
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DES failed to cross a heavily calcified lesion!!
Undamaged polymerUndamaged polymer
Severe polymer damageSevere polymer damage
Columbia University Medical CentreCardiovascular Research Foundation
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Mechanisms leading to incomplete stent apposition
Cook, S. et al. Circulation 2007;115:2426-2434
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The protocol sequence of IVUS imaging in very late ST patients is depicted in A, as follows: (1) After administration of nitroglycerin (0.2 mg), an
angiogram with the use of a 6F guiding catheter was performed to define the site of thrombotic stent occlusion
Cook, S. et al. Circulation 2007;115:2426-2434
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Clinical outcomes and Stent Thrombosis following off-label use of drug eluting stents
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Antiplatelets 4% to 30% of patients treated with conventional doses of
clopidogrel do not display adequate antiplatelet response 5% to 45% of patients treated with conventional doses of
aspirin do not display adequate antiplatelet response(Nguyen TA et al.JACC 2005;45:1157-1164.Gum PA Stone et al.JACC 2003;41:961-965)
Premature Discontinuation
Study Yes No RR (95% CI) PAR
Iakovou et al.,2005 (7)
5/17 (29%) 24/2,212 (1.0%)
27 (12, 63) 17%
Kuchulakanti et al.,2006 (8)
14/310 (4.5%) 24/2,658 (0.9%)
5 (3,10) 29%
PAR= Pr * [(RR-1)/Pr * (RR-1)+1]CI= confidence interval; DES= drug eluting stent; PAR= population attributable risk; Pr=prevalence of clopidogrel discontinuation; RR= relative risk
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Clopidogrel and DES
Late clinical events after clopidogrel discontinuation may limitthe benefit of drug-eluting stents.An observational study of DES versus BMS –BASKET-Late study
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Timing of late thrombotic events after clopidogrel discontinuation
Copyright ©2006 American College of Cardiology Foundation. Restrictions may apply.
Pfisterer, M. et al. J Am Coll Cardiol 2006;48:2584-2591
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SES Thrombosis in Diabetic And Non Diabetic Patients
JACC 2007, 50, 501
EVASTENT REGISTRY
0 100 200 300 400 500 600
0.85
0.90
0.95
1.00
Follow-up (days)
MAC
E fr
ee S
urvi
val
SVD db -
MVD db -
SVD db +
MVD db +Log Rank P <= 0.001
SVD db – 504 498 483 251 121 72
MVD db – 357 347 337 186 87 53
SVD db + 472 459 444 230 114 69
MVD + 334 321 312 164 91 97
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JACC 2007, 50, 501
0.80
0.85
0.90
0.95
1.00
0 200 400 600
Db - 870 861 835 448 216 129 pts
Db + 818 799 774 401 212 144 pts
Logrank p = 0.0001
Follow-up (days)
Su
rviv
al
Non-diabeticDiabetic
0.80
0.85
0.90
0.95
1.00
0 200 400 600
Db - 859 847 823 437 210 125 pts
Db + 800 776 755 394 202 135 pts
Log rank p = 0.003
Follow-up (days)
Ste
nt
Th
rom
bosi
s F
ree S
urv
ival
Non-diabeticDiabetic
EVASTENT REGISTRY – SES Diabetic Vs Non Diabetic Patients
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Follow-up (days)
0.80
0.85
0.90
0.95
1.00
0 200 400 600
Db - 858 835 805 426 203 123 pts
Db + 797 753 722 368 195 128 pts
Logrank p = 0.0001
TV
F F
ree S
urv
ival
Non-diabeticDiabetic
0 200 400 600Follow-up (days)
0.80
0.85
0.90
0.95
1.00
Db - 867 848 821 436 210 126 pts
Db + 814 775 747 388 200 134 pts
Log rank p = 0.032
Non-diabeticDiabetic
TL
R F
ree S
urv
ival
JACC 2007, 50, 501
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AMI Stent THROMB. vs DENOVO (table 1)Baseline clinical characteristics
STEMI(n=98)
STEMI with ST(n= 86)
P Value
Age (yrs) 62.9 _+ 10.3 66.0 _+11.9 0.06
Male 81 (82.7%) 68 (79.1%) 0.5
Cardiac risk factors
Hypertension 45 (45.9%) 44 (51.8%) 0.4
Diabetes Mellitus 14 (14.3%) 21 (25.3%) 0.06
Hypercholesterolemia 34 (34.7%) 37 (43.4%) 0.2
Current smoker 47 (48.0%) 23 (26.5%) 0.003
Family history of CAD 35 (35.7%) 23 (26.5%) 0.2
Creatine >= 1.5mg/dl 4 (4.1%) 13 (15.7%) 0.008
COPD 3 (3.1%) 8 (9.5%) 0.07
Prior MI 11 (11.2%) 59 (68.2%) < 0.0001
Prior stroke 0 (0%) 6 (7.1%) 0.007
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AMI Stent THROMB. vs DENOVO (table 2)ST characteristics (n=92)
Definite ST (ARC definition) 92 (100%)
Thrombosis timing (ARC definition)
Early (< 30 days) 59 (64.1%)
Late (30-360 days) 14 (15.2%)
Very Late (> 360 days) 19 (20.7%)
Clinical presentation at the Index procedure 43 (46.5%)
MI (acute or sub acute) 38 (41.9%)
UA/ NSTEMI stable angina or silent ischemia 11 (11.6%)
Double antiplatelet therapy at the moment of stent thrombosis 62 (67.4%)
Early discontinuation of double antiplatelet therapy 6 (6.9%)
Stent
BMS 22 (23.9%)
DES 70 (76.1%)
Stent Length 25.2_+ 12.7
Stent diameter 2.8_+ 0,3
ARC= Academic Reasearch Consortium; BMS= abre-metal stent; DES=drug eluting stent; MI=myocardial infarction; ST=stent thrombosis; UA/NSTEMI= unstable angina/non- ST-segment elevation myocardial infarction
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AMI Stent THROMB. vs DENOVO (table 3)Angiographic AnalysisSTEMI(n=98)
STEMI with ST(n= 92)
p Value
Pre-procedural TIMI flow <=1 77 (78.6%) 69 (80%) 0.8Post-procedural TIMI flow =3 95 (96.9%) 74 (80.4%) < 0.0001Pre-procedural TG >= 3 92 (93.9%) 92 (100%) 0.01Post-procedural myocardial blush <=1
1(1.0%) 12 (13.0%) 0.001
Post-procedural cTFC* 24.2 _+ 12.6 21.2 _+ 9.4 0.1Successful reperfusion 95 (96.9%) 74 (80.4%) <0.0001Distal Embolization 0(0%) 6 (6.5%) 0.01Residual dissection 1(1.0%) 15 (16.3%) <0.0001Post-procedural QCA analysisRVD (mm) 3.2 _+ 0.4 2.9 _+ 0.3 <0.0001Lesion length (mm) 2.9 _+ 2.6 7.0 _+ 4.7 < 0.0001MLD (mm) 2.9 _+ 0.4 2.0 _+ 0.7 < 0.0001Diameter stenosis (%) 8.1 _+ 6.6 31.8 _+ 24.9 < 0.0001
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Successful Reperfusion
Chechi, T. et al. J Am Coll Cardiol 2008;51:2396-2402
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All-Cause Mortality and Cumulative MACCE Rate
Chechi, T. et al. J Am Coll Cardiol 2008;51:2396-2402
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Stent thrombosis in DM NDMRisk factors for stent thrombosis after implantation of Sirolimus-
eluting stents in Diabetic and Nondiabetic patients.The EVASTENT Matched-Cohort Registry
Independent predictors of stent thrombosis
Parameter QR (95% CI) p Value
Overall population
Previous stroke 3.2 (0.99-1.0) 0.052
Renal failure 3.6 (1.6-7.7) 0.001
Insulin-requiring diabetes 2.7 (1.4-5.2) 0.004
Calcified lesion 3.7 (1.8-7.7) 0.001
Lower EF (per U) 0.95 (0.93-0.97) <= 0.001
Length stented (per mm) 1.01(1.0-1.03) 0.045
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Very Late DES Thrombosis On-Label Use>1 Year Post Implant Pooled RCTs
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Aalen-Nelson Estimate Curves of Cumulative Hazard Function for Stent Thrombosis
Park, D.-W. et al. J Am Coll Cardiol Intv 2008;1:494-503
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Kaplan-Meier Curves of Cumulative Incidence of Stent Thrombosis
Park, D.-W. et al. J Am Coll Cardiol Intv 2008;1:494-503
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Rates of Stent Thrombosis in Meta-analysisReference Year Patients Stents FU ST RateMoreno 2005 5,030 BMS 48%
SES 17%PES 34%
6–12 mn SAT: 0.35% (BMS = DES)LST: 0.23% (BMS = DES)
Bavry 2005 3,817 BMS 48%PES 52%
6–12 mn SAT + LST: 0.76% (PES = BMS)
Morice (REALITY)
2006 1,386 SES 51%PES 49%
12 mn SAT: SES 0.4%, PES 1.0%LST: SES 0%, PES 0.3%
Kastrati 2005 3,669 SES 50%PES 50%
6–13 mn SAT + LST: 1.0% (PES = SES)
Spalding 2007 1,748 BMS 50%SES 50%
48 mn SAT: SES 0.5%, BMS 0.5%LST: SES 0.3%, BMS 1.3%VLST: SES 2.8%, PES 1.7
Mauri 2007 4,545 SES 19%PES 31%BMS 50%
48 mn SAT: SES 0.5%, BMS 0.3%LST: SES 0.1%, BMS 1.0%
VLST: SES 0.9%, BMS 0.4%SAT: PES 0.5%, BMS 0.5%LST: PES 0.4%, BMS 0.3%
VLST: PES 0.9%, BMS 0.6%
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Preventive Strategies
Optimizing stent implantation Selection of the appropriate diameter and length of stent. Placement of excessively long DES (overstenting) should be avoided. Residual stent marginal dissections or significant stenoses should be
treated. Suboptimal under- or overdeployment of stent diameter should be
avoided. IVUS may be useful in optimizing deployment results. Some specific techniques may be associated with higher rates of ST.
Adjunctive therapy Dual antiplatelet therapy after DES implantation is crucial. Recently, the recommendation has been to extend this therapy for up to
12 months in patients at low risk for bleeding events. Preliminary data suggest that “triple” antiplatelet therapy may be
associated with a reduction in MACE, including ST, and may be a therapeutic option for patients at high risk for ST.
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Triple Versus Dual Antiplatelet Therapy
J. Am. Coll. Cardiol. 2005;46;1833-1837
Dual(n=1597)
Triple(n= 1415)
p Value
Stent thrombosis 9 (0.596) 1 (0.196) 0.024
Acute stent occlusion 3(0.296) 0 0.252
Sub acute stent thrombosis
6(0.396) 1(0.196) 0.223
Major cardiac events
Myocardial infarction 11(0.796) 3(0.296) 0.063
Target lesion revascularization
9(0.596) 1(0.196) 0.024
Repeat intervention 8(0.697) 1(0.196)
Emergency bypass 1(0.02) 0
Death 5(0.396) 3(0.296) 0.730
Primary end point 13(0.896) 4(0.396) 0.085
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