Stent thrombosis incidence in bare metal stents

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Introduction

Definition

Epidemiology and Demographics

Relation to Bare Metal Stents
Relation to Drug Eluting Stents
Relation to Antiplatelet Medications

Pathophysiology

Risk Factors

Relationship to Discontinuation of Antiplatelet Therapy

Treatment

Complications

Prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Smita Kohli, M.D.; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

Overview

Multiple contemporary studies involving single center and multi center experience suggests an overall lifetime incidence of stent thrombosis is 0.5 % - 2.5 %.[1] [2] [3] [4][5] There is some variation of these numbers with the definitions used. For instance, in a recent study of 8847 patients who received a BMS, a cumulative incidence of definite, probable or possible stent thrombosis (ST) over 15 months was 2.15% and that for definite ST was 0.61%.[1] In a study involving serial angiography after sirolimus-eluting stent (SES) and BMS implantation at 4, 11, and 21.2 ± 2.2 months, no BMS developed thrombus, however SES demonstrated the presence of thrombi and yellow plaques even as much as 2 years after implantation.[6]

Incidence in Bare Metal Stents

Incidence of Early ST in BMS

For purposes of discussion this group would include:

  • Intra-procedural ST
  • Acute ST: up to 24 hrs
  • Subacute ST: 24 hrs to 30 days

Supportive Trial Data

  • In study of 7484 patients with (intra vascular ultrasound study) IVUS before and after stenting, incidence of ST was 0.4% up to a week. The median time of ST was 24 hours and the minimum time was 1 hour.[7]
  • In a retrospective analysis 4509 patients the rate of subacute ST was 0.51%.[8]

Higher Incidence of Subacute ST in Special Patient Populations

  • In a group of 40 patients who underwent non cardiac surgery following BMS, the incidence of ST while on two antiplatelet agents appeared to be 2.5 % (one patient out of 40).[9]
  • Incidence of ST in patients with acute coronary syndrome(ACS) are higher than those with stable angina as demonstrated by ACUITY and TRITON-TIMI 38 trial databases.[10] [11]
  • The incident rates of early ST in ACS i.e STEMI and NSTEMI have shown to be 1.4 - 1.6%, and 0 - 2.9% respectively while ST incidence in patients with stable angina is 0 - 0.5%.[12]

Incidence of ST from 30 days up to 3 years or longer

This would include:

  • Late ST: 30 days to one year
  • Very late ST: more than one year, but generally less than 3 years
  • Later than 3 years

The reported incidence in this group ranges between 0-0.5%. Given the paucity of data only assumptions can be made for the group beyond 1-3 years.

Incidence of Late-ST

  • The incidence of late ST with BMS was 0.28% in a meta-analysis of 14 trials looking at 6675 patients.[13]
  • Long term aspirin therapy is necessary to reduce the incidence of late ST in patients with BMS.[14] [15]

Incidence of Very Late-ST

  • It appears that ST in the very late group is exceedingly rare.
  • In a meta-analysis of 14 trials looking at 6675 patients no patient presented with very late ST of BMS. However regular follow up of most patients confined to one year or less.[13]

References

  1. 1.0 1.1 Jensen LO, Maeng M, Kaltoft A, Thayssen P, Hansen HH, Bottcher M; et al. (2007). "Stent thrombosis, myocardial infarction, and death after drug-eluting and bare-metal stent coronary interventions". J Am Coll Cardiol. 50 (5): 463–70. doi:10.1016/j.jacc.2007.06.002. PMID 17662400.
  2. 2.0 2.1 2.2 Leon MB, Baim DS, Popma JJ, Gordon PC, Cutlip DE, Ho KK; et al. (1998). "A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators". N Engl J Med. 339 (23): 1665–71. doi:10.1056/NEJM199812033392303. PMID 9834303.
  3. 3.0 3.1 Moreno R, Fernández C, Hernández R, Alfonso F, Angiolillo DJ, Sabaté M; et al. (2005). "Drug-eluting stent thrombosis: results from a pooled analysis including 10 randomized studies". J Am Coll Cardiol. 45 (6): 954–9. doi:10.1016/j.jacc.2004.11.065. PMID 15766835.
  4. Cutlip DE, Baim DS, Ho KK, Popma JJ, Lansky AJ, Cohen DJ; et al. (2001). "Stent thrombosis in the modern era: a pooled analysis of multicenter coronary stent clinical trials". Circulation. 103 (15): 1967–71. PMID 11306525.
  5. Schühlen H, Kastrati A, Pache J, Dirschinger J, Schömig A (2001). "Incidence of thrombotic occlusion and major adverse cardiac events between two and four weeks after coronary stent placement: analysis of 5,678 patients with a four-week ticlopidine regimen". J Am Coll Cardiol. 37 (8): 2066–73. PMID 11419889.
  6. Awata M, Kotani J, Uematsu M, Morozumi T, Watanabe T, Onishi T; et al. (2007). "Serial angioscopic evidence of incomplete neointimal coverage after sirolimus-eluting stent implantation: comparison with bare-metal stents". Circulation. 116 (8): 910–6. doi:10.1161/CIRCULATIONAHA.105.609057. PMID 17684153.
  7. Cheneau E, Leborgne L, Mintz GS, Kotani J, Pichard AD, Satler LF; et al. (2003). "Predictors of subacute stent thrombosis: results of a systematic intravascular ultrasound study". Circulation. 108 (1): 43–7. doi:10.1161/01.CIR.0000078636.71728.40. PMID 12821553.
  8. Orford JL, Lennon R, Melby S, Fasseas P, Bell MR, Rihal CS; et al. (2002). "Frequency and correlates of coronary stent thrombosis in the modern era: analysis of a single center registry". J Am Coll Cardiol. 40 (9): 1567–72. PMID 12427407.
  9. Kałuza GL, Joseph J, Lee JR, Raizner ME, Raizner AE (2000). "Catastrophic outcomes of noncardiac surgery soon after coronary stenting". J Am Coll Cardiol. 35 (5): 1288–94. PMID 10758971.
  10. Aoki J, Lansky AJ, Mehran R, Moses J, Bertrand ME, McLaurin BT; et al. (2009). "Early stent thrombosis in patients with acute coronary syndromes treated with drug-eluting and bare metal stents: the Acute Catheterization and Urgent Intervention Triage Strategy trial". Circulation. 119 (5): 687–98. doi:10.1161/CIRCULATIONAHA.108.804203. PMID 19171852.
  11. Cook S, Windecker S (2009). "Early stent thrombosis: past, present, and future". Circulation. 119 (5): 657–9. doi:10.1161/CIRCULATIONAHA.108.842757. PMID 19204315.
  12. Wiviott SD, Braunwald E, McCabe CH, Horvath I, Keltai M, Herrman JP; et al. (2008). "Intensive oral antiplatelet therapy for reduction of ischaemic events including stent thrombosis in patients with acute coronary syndromes treated with percutaneous coronary intervention and stenting in the TRITON-TIMI 38 trial: a subanalysis of a randomised trial". Lancet. 371 (9621): 1353–63. doi:10.1016/S0140-6736(08)60422-5. PMID 18377975. Review in: ACP J Club. 2008 Sep 16;149(3):12
  13. 13.0 13.1 Bavry AA, Kumbhani DJ, Helton TJ, Borek PP, Mood GR, Bhatt DL (2006). "Late thrombosis of drug-eluting stents: a meta-analysis of randomized clinical trials". Am J Med. 119 (12): 1056–61. doi:10.1016/j.amjmed.2006.01.023. PMID 17145250.
  14. Moussa I, Di Mario C, Reimers B, Akiyama T, Tobis J, Colombo A (1997). "Subacute stent thrombosis in the era of intravascular ultrasound-guided coronary stenting without anticoagulation: frequency, predictors and clinical outcome". J Am Coll Cardiol. 29 (1): 6–12. PMID 8996288.
  15. 15.0 15.1 Ferrari E, Benhamou M, Cerboni P, Marcel B (2005). "Coronary syndromes following aspirin withdrawal: a special risk for late stent thrombosis". J Am Coll Cardiol. 45 (3): 456–9. doi:10.1016/j.jacc.2004.11.041. PMID 15680728.
  16. van Werkum JW, Heestermans AA, Zomer AC, Kelder JC, Suttorp MJ, Rensing BJ; et al. (2009). "Predictors of coronary stent thrombosis: the Dutch Stent Thrombosis Registry". J Am Coll Cardiol. 53 (16): 1399–409. doi:10.1016/j.jacc.2008.12.055. PMID 19371823.
  17. Ellis SG, Colombo A, Grube E, Popma J, Koglin J, Dawkins KD; et al. (2007). "Incidence, timing, and correlates of stent thrombosis with the polymeric paclitaxel drug-eluting stent: a TAXUS II, IV, V, and VI meta-analysis of 3,445 patients followed for up to 3 years". J Am Coll Cardiol. 49 (10): 1043–51. doi:10.1016/j.jacc.2007.01.015. PMID 17349883.


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