Late angiographic stent thrombosis (LAST): the cloud behind the drug-eluting stent silver lining?

The introduction of drug-eluting stents (DES), like that of bare-metal stents during the balloon angioplasty era, represents yet another quantum advancement towards overcoming the challenges of restenosis. However, recent concerns over late angiographic stent thrombosis (LAST) have tempered the initial enthusiasm. Although the main time frame of thrombosis is believed to be within the first 6 months, later occurrences have been increasingly reported. We present a patient who suffered an acute myocardial infarction secondary to LAST of a DES implanted 14 months prior. The current literature regarding LAST, as well as major DES trials and meta-analyses, are reviewed. The pathophysiology of stent thrombosis and hypersensitivity, adjunct antiplatelet pharmacology, as well as comparison of the two available DES are also discussed. Although study results vary, one common recommendation appears to be prolonged dual antiplatelet therapy. The recent Food and Drug Administration advisory panel recommendations are also discussed. Further investigation into patient selection as well as novel platforms are needed to assess and improve the DES benefit-to-risk ratio and to more clearly define its role in modern percutaneous coronary therapy.