Very Late Stent Thrombosis in Drug-Eluting Stents New Observations and Clinical Implications

Abstract

Despite the reduction in stent failure with newer-generation drug-eluting stents, very late stent thrombosis (VLST) remains an unpredictable and potentially catastrophic complication of coronary revascularization procedures and is associated with high morbidity and mortality. Here, we present an updated overview of the latest advances in understanding the causes of VLST. Clinical studies that revealed potential risk factors and pathophysiologic studies on the mechanisms of VLST are discussed. Importantly, novel insights from recent advances in intravascular imaging are included. To date, there is no clinical guideline for VLST treatment. We propose an evidence-based recommendation that an intravascular-imaging-informed percutaneous coronary intervention strategy combined with optimized antiplatelet therapy is the foundation for successful VLST clinical management. Moreover, the future of VLST prevention, such as improved patient risk stratification and advances in addressing late stent failure, are also discussed.

Very late stent thrombosis associated with COVID-19 infection: a case report and review of the literature

“…[5] Previous reports have shown that the risk of VLST persists even until five years post DES implantation. [4] Predictors for late ST/VLST include younger patients, smokers, STEMI at time of initial DES implantation, number of diseased vessels, type C lesions, longer stent length and presence of overlapping stents. [6] The risk of VLST at the time of DES implantation can be estimated by a recently proposed "VLST scoring system".…”

“…It does, however, have life-threatening consequences resulting in acute MI or death, with mortality reported to be as high as 45%. [4] We present a middle-aged male with a prior history of coronary artery disease (CAD), who developed acute ST-segment elevation myocardial infarction (STEMI) due to VLST occurring two years after DES implantation following COVID-19 infection.…”

Adverse Events in Primary Percutaneous Coronary Angioplasty With Drug-Eluting Stents Compared With Drug-Coated Balloons: A Retrospective Outlook

“…Stenting with a DES reduces target vessel revascularization (TVR) but there is no benefit in aborting recurrent AMI [4]. This was shown in a study that demonstrated an increased incidence of stent thrombosis among AMI patients treated with DES as compared with balloon angioplasty alone, thus paving a potential role of a DCB in PPCI [5]. The presence of a drug on the semi-compliant DCB provides a potential advantage in reducing the potential risk of in-stent restenosis or stent thrombosis [12].…”

“…Drug-eluting stents (DES) are implanted in the blocked arteries after the restoration of thrombolysis in myocardial infarction (TIMI) flow during PPCI [3]. Various large trials have proven DES to reduce repeat revascularization, however, they do not reduce mortality as compared to balloon angioplasty alone and it increases the long-term risk of stent thrombosis and stent restenosis [4][5].…”

The Association Between S100A8/A9 and the Development of Very Late Stent Thrombosis in Patients With Acute Myocardial Infarction

“… 1 Very late stent thrombosis (VLST, stent thrombosis occurring more than 1 year after stent implantation, usually out of the time window recommended by the guidelines for antiplatelet therapy and often overlooked) is an uncommon yet catastrophic event after PCI, usually manifesting as recurrent AMI with poor prognosis or sudden death. 2 , 3 Despite being recognized for over a decade, the detailed mechanisms underlying VLST remain poorly understood, and the insights that can translate into prediction, precaution, and management of VLST are lacking.…”