Late and very late thrombosis of drug-eluting stents: evolving concepts and perspectives

Area of Science:

• Cardiovascular Medicine
• Interventional Cardiology
• Biomaterials Science

Background:

• Coronary stents are crucial for percutaneous coronary revascularization, improving outcomes by reducing vessel closure and restenosis.
• Stent thrombosis (ST), though rare, is a severe complication of percutaneous coronary intervention (PCI), potentially leading to myocardial infarction and sudden death.
• Advances in stent implantation and dual antiplatelet therapy (DAPT) have significantly lowered ST rates.

Purpose of the Study:

• To review the pathophysiology of late drug-eluting stent (DES) thrombosis.
• To discuss the current understanding and ongoing controversies surrounding the incremental risk of ST with DES compared to bare-metal stents (BMS).
• To explore the role of DAPT duration and novel stent designs in managing ST.

Main Methods:

• Literature review of studies comparing BMS and DES regarding stent thrombosis.
• Analysis of data on the incidence and timing of ST in different stent types.
• Discussion of clinical significance and risk factors for late DES thrombosis.

Main Results:

• Bare-metal stent (BMS) thrombosis occurs in <1% of cases, typically within the first month.
• Concerns exist regarding late ST with drug-eluting stents (DES), particularly in complex lesions not studied in initial trials.
• Recent data suggest a potential 0.5% increased long-term thrombosis risk with DES, though clinical significance is debated.

Conclusions:

• While DES have improved revascularization, late ST remains a concern, especially in complex subsets.
• Optimal DAPT duration and novel stent designs are critical areas for future research to minimize ST risk.
• Further understanding of late DES thrombosis pathophysiology is needed.