Subacute Stent Thrombosis After Primary Stenting of Totally Occluded Left Anterior Descending Coronary Artery

- Operator : Seong-Wook Park

Subacute Stent Thrombosis After Primary Stenting of Totally Occluded Left Anterior Descending Coronary Artery

- Operator: Seong-Wook Park, MD, PhD, Korea
Case presentation
A 50 year-old female patient was presented to the emergency room with persistent chest pain for 4 hours. She had a hypercholesterolemia as a coronary risk factor. Baseline ECG showed a ST elevation on precordial leads. She was hemodynamically stable. She underwent emergent coronary angiography for primary angioplasty.
Baseline coronary angiography
1. Coronary angiogram showed a total occlusion in the proximal LAD with TIMI 0 flow (Figure 1).
2. The RCA and LCX were normal. However, the intercoronary collaterals were not seen.
Procedure

A 7F sheath was inserted through the right femoral artery. The left coronary was engaged with a 7F Judkins catheter through the right femoral sheath. Coronary angiography showed a total occlusion in the proximal LAD with TIMI 0 flow. Initially, a Choice PT wire was inserted into the LAD. After that, the occluded LAD was predilated with a 3.0x20 mm balloon at nominal pressure (Figure 2). The following angiography in LAO cranial projection showed a diffuse stenosis in the proximal and middle LAD with TIMI 3 flow (Figure 3). After an additional predilatation, the distal LAD lesion was stented with a 3.0x26 mm heparin coated JOSTENT FlexMaster at 8atm (Figure 4). And a 3.5x19 mm heparin coated JOSTENT FlexMaster was also implanted at the proximal to the first stent with overlapping (Figure 5). After stenting, the angiography revealed an indentation of the middle portion of the first stent and a compromised diagonal branch (Figure 6). After the diagonal branch was assessed with a Choice PT wire, an additional high pressure dilatation in the first stent was performed with the stent balloon at 8 atm (Figure 7). And then, a kissing balloon dilatation was performed in the LAD with a 3.5x26mm stent balloon at 8 atm and the diagonal with a 2.5x20mm balloon at 6 atm (Figure 8). The final angiography showed a well deployed stent in the LAD without residual stenosis with the patent diagonal branch and TIMI 3 flow (Figure 9). Intravascular ultrasound after stenting showed a good result with a well expanded stent with a intraluminal pedunculated mass suggesting thrombus (Figure 10). Therefore, we decided to continue administrating heparin. Immediately after coronary stenting, clopidogrel 300mg loading dose was given to patient. Thereafter clopidogrel 75mg was given once a day.

Forty hours after the primary stenting, the patient suffered chest pain and EKG revealed ST elevation on precordial leads. Emergent coronary angiography was done for evaluation of chest pain. Angiography revealed a total occlusion of the previous stenting site at the proximal LAD with TIMI 0 flow (Figure 11), which represented a subacute stent thrombosis. Abciximab (glycoprotein IIb/IIIa receptor blocker) was adminstrated to reduce thrombus burden and a Choice PT wire was inserted in the LAD. And then, an Export catheter developed for aspiration of the intracoronary thrombus was used for reducing thrombus burden (Figure 12). After aspiration, the following angiography revealed an improved TIMI flow in the lesion site (Figure 13). Thus balloon angioplasty was done twice with a 3.0x20 mm balloon at 10 and 20 atm (Figure 14, Figure 15). Final angiography showed a well deployed stent in the LAD without residual stenosis or dissection and the presence of TIMI 3 flow (Figure 16). Hospital course was uneventful after procedure.

Comments

  • Myung-Ho Jeong 2003-10-13 It is a really interesting case. Subacute stent thrombosis was developed even after heparin-coated stents and continous heparin therapy with Plavix after stenting. So ReoPro with LMWH during the first procedure would be more helpful in your casse. Thank you for informative case!
  • Seong-Wook Park 2003-10-13 Thank you for the excellent comments. I totally agree with your opinion that the use of ReoPro should have decreased the chance of subacute stent thrombosis. According to the recent paper by E Cheneau et al (Circulation 2003;108:43-47), the presence of intracoronary thrombus was one of the predictors of stent thrombosis. For this particular patient, we had decided not to give provisional ReoPro since the thrombus was not big enough to compromise distal flow (Actually it was rather small!). I think we need to be a little more generous to use ReoPro for patients undergoing PCI for acute MI, despite of tight constraint by the Korean insurance system. The other lesson we may learn from this case would be that we can not completely prevent stent thrombosis even if heparin-coated stent and dual antiplatelet therapy are used. The data from Benestent II and Hepacoat study adopting heparin-coated stent suggest that we should apply the same antiplatelet therapy even after heparin-coated stenting. Regarding the use of LMWH instead of unfractionated heparin, I am not sure if there is any report that LMWH is superior to unfractionated heparin for prevention of stent thrombosis, or LMWH leads to more favorable outcome after PCI. We may need to do a prospective, comparative trial. Thank you.

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