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17 Years Not Too Late: A Case of Extremely Late Stent Thrombosis
Saloni Jain1, Noreen Syed2, Jorge Naranjo2
1Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.
Insights
Stent thrombosis (ST) can occur over 15 years after drug-eluting stent (DES) implantation. This rare case highlights the importance of advanced imaging for managing very late ST.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Devices
Background:
- Stent thrombosis (ST) is a critical complication following percutaneous coronary intervention.
- ST exhibits a U-shaped mortality curve, with increased risk in early and very late phases.
- Drug-eluting stents (DES) are commonly used, but long-term complications like ST remain a concern.
Observation:
- A patient presented with ST-segment elevation myocardial infarction due to ST of a DES implanted 17 years prior.
- Angiography and intravascular ultrasound confirmed the presence of thrombus within the old stent.
- Risk factors identified included patient's smoking history and aspirin interruption.
Findings:
- This case represents a rare instance of very, very late ST presenting 17 years post-DES implantation.
- Potential mechanisms for this late ST include neoatherosclerosis with plaque rupture and impaired re-endothelialization.
- Successful treatment involved mechanical thrombectomy, balloon angioplasty, and a second DES guided by intravascular ultrasound.
Implications:
- Extremely late ST, occurring more than 15 years after DES, is unpredictable but possible.
- Intraprocedural multimodal imaging is crucial for effective management of complex intrastent lesions.
- Understanding long-term stent behavior is vital for optimizing patient outcomes and device design.
Background:
Stent thrombosis (ST) is a serious complication of percutaneous coronary intervention, portending to significant morbidity and mortality with a U-shaped relationship with increased mortality in early and very late ST.
Case Summary:
The patient presented with an inferior wall ST-segment elevation myocardial infarction and was found to have ST of a prior drug-eluting stent (DES) 17 years postimplantation. Thrombus was confirmed during angiography and with intravascular ultrasound. It was treated with mechanical thrombectomy, balloon angioplasty, and a second layer of intravascular ultrasound-guided DES with excellent results.
Discussion:
This was a rare case of very, very late-presenting ST, which occurred 17 years after the index DES. This patient's risk factors include smoking and aspirin interruption. Possible mechanisms were neoatherosclerosis with plaque rupture and impaired re-endothelialization.
Take-Home Message:
Unpredictable, extremely late ST can still happen more than 15 years after an index DES. Intraprocedural multimodal imaging remains pivotal in intrastent lesion management.
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