Skip to main content

Advertisement

Log in

Stent Thrombosis: Current Management and Outcomes

  • Coronary Artery Disease (D Feldman, Section Editor)
  • Published:
Current Treatment Options in Cardiovascular Medicine Aims and scope Submit manuscript

Opinion statement

Stent thrombosis (ST) is an uncommon but highly morbid complication of percutaneous coronary interventions. The mechanisms leading to ST are heterogeneous, likely accounting for the variable timing and outcomes of ST. For the clinician, it is important to recognize major risk factors for ST, including discontinuation of dual antiplatelet therapy. Once ST occurs, management includes intensive antithrombotic and antiplatelet therapies. Newer antiplatelet agents may reduce the risk of ST and possibly minimize adverse outcomes after presentation with ST.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Mauri L, Hsieh WH, Massaro JM, Ho KK, D’Agostino R, Cutlip DE. Stent thrombosis in randomized clinical trials of drug-eluting stents. N Engl J Med. 2007;356:1020–9.

    Article  CAS  PubMed  Google Scholar 

  2. Kirtane AJ, Stone GW. How to minimize stent thrombosis. Circulation. 2007;115:2344–51.

    Article  Google Scholar 

  3. Cutlip DE, Windecker S, Mehran R, et al. Clinical end points in coronary stent trials: a case for standardized definitions. Circulation. 2007;115:2344–51.

    Article  PubMed  Google Scholar 

  4. Cutlip DE, Windecker S, Mehran R, et al. Clinical end points in coronary stent trials: a case for standardized definitions. Circulation. 2007;115(17):2344–51.

    Article  PubMed  Google Scholar 

  5. Van Werkum JW, Heestermans AA, Zomer AC, et al. Predictors of coronary stent thrombosis: the Dutch Stent Thrombosis Registry. J Am Coll Cardiol. 2009;53:1399–409.

    Article  PubMed  Google Scholar 

  6. Aoki J, Lansky AJ, Mehran R, et al. 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. 2009;119:687–98.

    Article  CAS  PubMed  Google Scholar 

  7. Garg S, Serruys PW. Coronary stents: current status. J Am Coll Cardiol. 2010;56(Suppl):S1–42.

    Article  CAS  PubMed  Google Scholar 

  8. Virmani R, Farb A, Guagliumi G, et al. Drug-eluting stents: caution and concerns for long-term outcome. Coron Artery Dis. 2004;15:313–8.

    Article  PubMed  Google Scholar 

  9. McFadden EP, Stabile E, Regar E, et al. Late thrombosis in drug-eluting coronary stents after discontinuation of antiplatelet therapy. Lancet. 2004;364:1519–21.

    Article  CAS  PubMed  Google Scholar 

  10. Daemen J, Wenaweser P, Tsuchida K, et al. Early and late coronary stent thrombosis of sirolimus-eluting and paclitaxel-eluting stents in routine clinical practice: data from a large two-institutional cohort study. Lancet. 2007;369:667–78.

    Article  CAS  PubMed  Google Scholar 

  11. Kumar DK, et al. Virchow’s contribution to the understanding of thrombosis and cellular biology. Clin Med Res. Dec 2010. Interesting article about Virchow’s discovery and an exciting part of the history of medicine.

  12. Virchow RC. Thrombosis and emboli. [Tr. by Matzdorff AC, Bell WR.]. Canton: Science History Publications; 1998.

    Google Scholar 

  13. Conde ID, Kleinman NS. Arterial thrombosis for the interventional cardiologist: from adhesion molecules and coagulation factors to clinical therapeutics. Catheter Cardiovasc Interv. 2003;60:236–46.

    Article  PubMed  Google Scholar 

  14. D’Ascenzo F, Bollati M, Clementi F, et al. Incidence and predictors of coronary stent thrombosis: evidence from an international collaborative meta-analysis including 30 studies, 221,066 patients, and 4276 thromboses. Int J Cardiol. 2013;167:575–84.

    Article  PubMed  Google Scholar 

  15. Nakano M, Virmani R, et al. Causes of early stent thrombosis in patients presenting with acute coronary syndrome—an ex vivo human autopsy study. J Am Coll Cardiol. 2014;63:2510–20. Well done autopsy study with new insights into mechanisms of ST.

    Article  PubMed  Google Scholar 

  16. Serruys PWW, Kutryk MJ, Ont AT. Coronary-artery stents. N Eng J Med. 2006;354:483–95.

    Article  CAS  Google Scholar 

  17. Kotani J, Awata M, Nanto S, et al. Incomplete neointimal coverage of sirolimus eluting stents: angioscopic findings. J Am Coll Cardiol. 2006;47:2108–11.

    Article  CAS  PubMed  Google Scholar 

  18. Stefanini GG, Byrne RA, Serruys PW, et al. Biodegradable polymer drug-eluting stents reduce the risk of stent thrombosis at 4 years in patients undergoing percutaneous coronary intervention: a pooled analysis of individual patient data from the ISAR-TEST 3, ISAR-TEST 4 and LEADERS randomized trials. Eur Heart J. 2012;33:1214–22.

    Article  CAS  PubMed  Google Scholar 

  19. Sarno G, et al. Stent thrombosis in new-generation drug-eluting stents in patients with STEMI undergoing primary PCI. J Am Coll Cardiol, 2014:18–24.

  20. Palmerini T et al. Stent thrombosis with drug-eluting and bare-metal stents: evidence from a comprehensive network meta-analysis. Lancet. 2012;379(9824):1393–402.

    Article  CAS  PubMed  Google Scholar 

  21. Palmerini T et al. Stent thrombosis with everolimus-eluting stents: meta-analysis of randomized controlled trials. Circ Cardiovasc Interv. 2012;5(3):357–64.

    Article  CAS  PubMed  Google Scholar 

  22. Bangalore S et al. Outcomes with various drug eluting or bare metal stents in patients with diabetes mellitus: mixed treatment comparison analysis of 22,844 patient years of follow-up from randomised trials. BMJ. 2012;345:e5170.

    Article  PubMed Central  PubMed  Google Scholar 

  23. Park S-J, Kang S-J, Virmani R, Nakano M, Ueda Y. In-stent neoatherosclerosis: a final common pathway of late stent failure. J Am Coll Cardiol. 2012;59:2051–7.

    Article  PubMed  Google Scholar 

  24. Mehran R, Baber U, Steg PG, et al. Cessation of dual antiplatelet treatment and cardiac events after percutaneous coronary intervention (PARIS): 2 year results from a prospective observational study. Lancet. 2013;382:1714–22.

    Article  PubMed  Google Scholar 

  25. Amsterdam EA, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes. Circulation 2014 Sept 23, [Epub ahead of print]. The updated AHA/ACC guidelines for ACS which are worthwhile reading as they are very pertinent to our daily practice.

  26. Windecker S, Kohl P, Alfonso F, et al. 2014 ESC/EACTS guidelines on myocardial revascularization: the task force on myocardial revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-thoracic Surgery (EACTS) developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014 Aug 29 [E-pub ahead of print].

  27. Hashikata T, et al. Neointimal coverage of zotarolimus-eluting stent at 1, 2 and 3 months’ follow-up: an optical coherence tomography study. Heart Vessel. 2014 Nov 2. [Epub ahead of print].

  28. Mauri L, Kereiakes DJ, et al. for the DAPT Study Investigators. Twelve or 30 months of dual antiplatelet therapy after drug eluting stents. N Eng J Med 2014 Nov 16. The findings of the DAPT study may very well affect how long we treat patients with DAPT. Several societies have issued statements regarding this trial and it is going to be interesting to see how this will affect the European and American guidelines. In regards to ST this is an important, randomized trial.

  29. Price MJ, Berger PB, Teirstein PS, et al. Standard- vs high-dose clopidogrel based on platelet function testing after percutaneous coronary intervention: the GRAVITAS randomized trial. JAMA. 2011;305(11):1097–105.

    Article  CAS  PubMed  Google Scholar 

  30. Alfonso F, Suarez A, Angiolillo DJ, et al. Findings of intravascular ultrasound during acute stent thrombosis. Heart. 2004;90:11455–9.

    Article  Google Scholar 

  31. Hoye A, Iakovou I, Ge L, et al. Long-term outcomes after stenting of bifurcation lesions with the “crush” technique: predictors of an adverse outcome. J Am Coll Cardiol. 2006;47:1949–58.

    Article  PubMed  Google Scholar 

  32. Steigen TK, Maeng M, Wiseth R, et al. Randomized study on simple versus complex stenting of coronary artery bifurcation lesions: the Nordic bifurcation study. Circulation. 2006;114:1955–61.

    Article  PubMed  Google Scholar 

  33. Choi SY, Witzenbichler B, Maehara A, et al. Intravascular ultrasound findings of early stent thrombosis after primary percutaneous intervention in acute myocardial infarction: a Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) substudy. Circ Cardiovasc Interv. 2011;4:239–47.

    Article  PubMed  Google Scholar 

  34. Holmes DR, Kreiakes DJ, Garg S, et al. Stent thrombosis. J Am Coll Cardiol. 2010;56:1357–65.

    Article  PubMed  Google Scholar 

  35. Chechi T, Vecchio S, Vittori G, et al. ST-segment elevation myocardial infarction due to early and late stent thrombosis a new group of high-risk patients. J Am Coll Cardiol. 2008;51:2396–402.

    Article  PubMed  Google Scholar 

  36. Forbert O, Lagerqvist B, Olivecrona GK, et al. Thrombus aspiration during ST-segment elevation myocardial infarction. N Engl J Med. 2013;369:1587–97.

    Article  Google Scholar 

  37. Armstrong EJ, Sab S, Singh GD, et al. Predictors and outcomes of recurrent stent thrombosis: results from a multicenter registry. J Am Coll Cardiol Intv. 2014;7(10):1105–13. doi:10.1016/j.jcin.2014.05.017. Major study focusing on recurrent ST.

    Article  Google Scholar 

  38. Reeves RR, Patel M, Armstrong EJ, Sab S, Waldo SW, Yeo K‐K, Shunk KA, Low RI, Rogers JH, Mahmud E. Angiographic characteristics of definite stent thrombosis: role of thrombus grade, collaterals, epicardial coronary flow, and myocardial perfusion. CCI 2014.

  39. Shahzad A, for the HEAT-PPCI trial investigators, et al. Unfractionated heparin versus bivalirudin in primary percutaneous coronary intervention (HEAT-PPCI): an open-label, single centre, randomised controlled trial. Lancet. 2014;384(9957):1849–58. Another very recent trial showing increased risk of ST in a contemporary clinical setting.

    Article  CAS  PubMed  Google Scholar 

  40. Kubo T, Imanishi T, Takarada S, et al. Assessment of culprit lesion morphology in acute myocardial infarction: ability of optical coherence tomography compared with intravascular ultra- sound and coronary angioscopy. J Am Coll Cardiol. 2007;50:933–9.

    Article  PubMed  Google Scholar 

  41. Alfonso F, Suarez A, Angiolillo DJ, et al. Findings of intravascular ultrasound during acute stent thrombosis. Heart. 2004;90:1455–9.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  42. Kobayashi Y, Teirstein P, Linnemeier T, Stone G, Leon M, Moses J. Rotational atherectomy (stent ablation) in a lesion with stent under-expansion due to heavily calcified plaque. Catheter Cardiovasc Interv. 2001;52:208–11.

    Article  CAS  PubMed  Google Scholar 

  43. Latib A, Takagi K, Chizzola G, et al. Excimer Laser LEsion modification to expand non-dilatable stents: the ELLEMENT registry. Cardiovasc Revasc Med. 2014;15:8–12.

    Article  PubMed  Google Scholar 

  44. Kimura T, Morimoto T, et al. Comparisons of baseline demographics, clinical presentation, and long-term outcome among patients with early, late, and very late stent thrombosis of sirolimus-eluting stents. Observations from the Registry of Stent Thrombosis for Review and Reevaluation (RESTART). Circulation 2010 June 21.

  45. Armstrong EJ, Feldman DN, Wang TY, et al. Clinical presentation, management, and outcomes of angiographically documented early, late, and very late stent thrombosis. J Am Coll Cardiol Intv. 2012;5(2):131–40.

    Article  Google Scholar 

  46. Kohn CG, Kluger J, Azeem M, Coleman CI. Short-term consequences of angiographically confirmed coronary stent thrombosis. PLoS ONE. 2013;8(10):e77330.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  47. Armstrong EJ et al. Mortality after presentation with stent thrombosis is associated with time from index percutaneous coronary intervention: a report from the VA CART program. Am Heart J. 2014;168(4):560–7.

    Article  PubMed  Google Scholar 

  48. Armstrong EJ et al. Predictors and outcomes of recurrent stent thrombosis. J Am Coll Cardiol Intv. 2014;7(10):1105–13.

    Article  Google Scholar 

  49. Brener SJ, Cristea E, Kirtane AJ, et al. Intra-procedural stent thrombosis: a new risk factor for adverse outcomes in patients undergoing percutaneous coronary intervention for acute coronary syndromes. JACC Cardiovasc Interv. 2013;6:36–43. Well written article with focus on IPST.

    Article  PubMed  Google Scholar 

  50. Motalescot G, Wiviott SD, Braunwald E, et al. Prasugrel compared with clopidogrel in patients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (TRITON-TIMI 38): double-blind, randomized controlled trial. Lancet. 2009;373:723–31.

    Article  Google Scholar 

  51. Steg PG, Harrington RA, Emanuelsson H, et al. Stent thrombosis with ticagrelor versus clopidogrel in patients with acute coronary syndromes: an analysis from the prospective, randomized PLATO trial. Circulation. 2013;128:1055–65.

    Article  CAS  PubMed  Google Scholar 

  52. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with Non–ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014.

  53. Wiviott SD, Braunwald E, McCabe CH, et al. 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. 2008;371:1353.

    Article  CAS  PubMed  Google Scholar 

  54. Steg PG, Harrington RA, Emanuelsson H, et al. Stent thrombosis with ticagrelor versus clopidogrel in patients with acute coronary syndromes: an analysis from the prospective, randomized PLATO trial. Circulation. 2013;128:1055.

    Article  CAS  PubMed  Google Scholar 

  55. Becker EM, Perzborn E, Klipp A, et al. Effects of rivaroxaban, acetylsalicylic acid and clopidogrel as monotherapy and in combination in a porcine model of stent thrombosis. J Thromb Haemost. 2012;10:2470–80.

    Article  CAS  PubMed  Google Scholar 

  56. Gibson CM, Chakrabarti AK, Mega JL, et al. Reduction of stent thrombosis in patients with acute coronary syndrome treated with rivaroxaban in ATLAS ACS 2-TIMI 51. J Am Coll Cardiol. 2013;62:286–90.

    Article  CAS  PubMed  Google Scholar 

  57. Bonaca MP, Morrow DA, et al. Coronary stent thrombosis with varoxapar versus placebo: results from the TRA 2°P-TIMI 50 trial. J Am Coll Cardiol. 2014;64:2309–17.

    Article  CAS  PubMed  Google Scholar 

  58. Stone GW, Witzenbichler B, Guagliumi G, et al. Bivalirudin during primary PCI in acute myocardial infarction. N Engl J Med. 2008;358:2218–30.

    Article  CAS  PubMed  Google Scholar 

  59. Steg PG, van’t Hof A, Hamm CW, et al. Bivalirudin started during emergency transport for primary PCI. N Engl J Med. 2013;369:2207–17.

    Article  CAS  PubMed  Google Scholar 

  60. Curzen N, Gurbel PA, Myat A, et al. What is the optimum adjunctive reperfusion strategy for primary percutaneous coronary intervention? Lancet. 2013;382:633–43.

    Article  PubMed  Google Scholar 

  61. Witzenbichler B, Maehara A, Weisz G, et al. Relationship between intravascular ultrasound guidance and clinical outcomes after drug-eluting stents: the Assessment of Dual Antiplatelet Therapy with Drug-Eluting Stents (ADAPT-DES) study. Circulation. 2014;129:463–70. Important article, making a strong case for IVUS guided PCI.

    Article  CAS  PubMed  Google Scholar 

  62. Palmerini T, Biondi-Zoccai G, Della Riva D, et al. Clinical outcomes with bioabsorbable polymer- versus durable polymer-based drug-eluting and bare-metal stents: evidence from a comprehensive network meta-analysis. J Am Coll Cardiol. 2014;63(4):299–307.

    Article  CAS  PubMed  Google Scholar 

Download references

Compliance with Ethics Guidelines

Conflict of Interest

Dr. Per Sommer reports no conflicts of interest.

Dr. Ehrin J. Armstrong declares consulting fees from Spectranetics and Abbott Vascular.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Ehrin J. Armstrong MD, MSc.

Additional information

This article is part of the Topical Collection on Coronary Artery Disease

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sommer, P., Armstrong, E.J. Stent Thrombosis: Current Management and Outcomes. Curr Treat Options Cardio Med 17, 7 (2015). https://doi.org/10.1007/s11936-015-0365-2

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11936-015-0365-2

Keywords

Navigation