scholarly journals Pathologic Etiologies of Late and Very Late Stent Thrombosis following First-Generation Drug-Eluting Stent Placement

Thrombosis ◽  
2012 ◽  
Vol 2012 ◽  
pp. 1-16 ◽  
Author(s):  
Fumiyuki Otsuka ◽  
Masataka Nakano ◽  
Elena Ladich ◽  
Frank D. Kolodgie ◽  
Renu Virmani
Keyword(s):  
First Generation ◽  
Bare Metal Stents ◽  
Drug Eluting Stent ◽  
Metal Stents ◽  
Steady Increase ◽  
Stent Fracture ◽  
Fibrin Deposition ◽  
Very Late Stent Thrombosis ◽  
Bifurcation Stenting ◽  
Drug Eluting

Several randomized and observational studies have reported steady increase in cumulative incidence of late and very late ST (LST/VLST) following first-generation drug-eluting stents (DES: sirolimus-(SES) and paclitaxel-(PES)) up to 5 years. Pathologic studies have identified uncovered struts as the primary substrate responsible for LST/VLST following DES, where delayed arterial healing is associated with stent struts penetrating into the necrotic core, long/overlapping stents, and bifurcation stenting especially in flow divider region. Grade V stent fracture also induces LST/VLST and restenosis. Hypersensitivity reaction is exclusive to SES as an etiology of LST/VLST, whereas malapposition secondary to excessive fibrin deposition is associated with PES. Uncovered struts can be identified in SES and PES with duration of implant beyond 12 months, particularly in stents placed for “off-label” indications. Neoatherosclerosis is another important contributing factor for VLST in DES and bare metal stents (BMS); however, DES shows rapid and more frequent development of neoatherosclerosis than BMS. Future pathologic studies should address the long-term safety of newer generation DES including zotarolimus- and everolimus-eluting stents in terms of the improvement in reendothelialization, decreased inflammation and fibrin deposition as well as a lower incidence of stent fracture-related adverse events, and reduced neoatherosclerosis, which likely contribute to the decreased risk of LST/VLST and better patient outcomes.

scholarly journals Histopathologically confirmed very late stent thrombosis associated with stent fracture after implantation of first-generation drug eluting stent

2020 ◽  
Vol 27 (2) ◽  
pp. 204-205
Author(s):  
Takao Konishi ◽  
Naohiro Funayama ◽  
Tadashi Yamamoto ◽  
Daisuke Hotta ◽  
Yuta Kobayashi ◽  
...  
Keyword(s):  
Stent Thrombosis ◽  
First Generation ◽  
Drug Eluting Stent ◽  
Stent Fracture ◽  
Late Stent Thrombosis ◽  
Very Late Stent Thrombosis ◽  
Drug Eluting

Pathology of First-generation Drug-eluting Stents in Humans

2011 ◽  
Vol 3 (1) ◽  
pp. 52
Author(s):  
Fumiyuki Otsuka ◽  
Masataka Nakano ◽  
Saami K Yazdani ◽  
Elena Ladich ◽  
Frank D Kolodgie ◽  
...  
Keyword(s):  
First Generation ◽  
Underlying Mechanism ◽  
Drug Eluting Stents ◽  
Steady Increase ◽  
Stent Fracture ◽  
Late Stent Thrombosis ◽  
Flow Divider ◽  
Bifurcation Stenting ◽  
Drug Eluting

First-generation sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) have dramatically reduced restenosis, although concern still exists about the long-term safety of this technology since observational studies have shown a steady increase in the rate of late stent thrombosis (LST), an infrequent but catastrophic complication. Although the mechanisms of LST are multifactorial, our laboratory has demonstrated that delayed arterial healing accompanied by poor endothelialisation is the primary pathogical substrate underlying this event. Delayed arterial healing is associated with penetration of necrotic core, long/overlapping stents and bifurcation stenting, especially in flow divider (high shear) regions. Grade V stent fracture is also associated with adverse pathogical findings including LST and restenosis. Moreover, localised hypersensitivity reaction is exclusive to SES as an underlying mechanism of LST, while malapposition secondary to excessive fibrin deposition is associated with PES. Uncovered struts are still identified in both SES and PES with implant duration beyond 12 months, particularly in stents placed for ‘off-label’ indications. In conclusion, the first generation of drug-eluting stents (DES) certainly reduce neointimal growth but this comes at the price of delayed healing.

Pathology of First-generation Drug-eluting Stents in Humans

2011 ◽  
Vol 6 (1) ◽  
pp. 28
Author(s):  
Fumiyuki Otsuka ◽  
Masataka Nakano ◽  
Saami K Yazdani ◽  
Elena Ladich ◽  
Frank D Kolodgie ◽  
...  
Keyword(s):  
First Generation ◽  
Underlying Mechanism ◽  
Drug Eluting Stents ◽  
Steady Increase ◽  
Stent Fracture ◽  
Late Stent Thrombosis ◽  
Flow Divider ◽  
Bifurcation Stenting ◽  
Drug Eluting

First-generation sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) have dramatically reduced restenosis, although concern still exists about the long-term safety of this technology since observational studies have shown a steady increase in the rate of late stent thrombosis (LST), an infrequent but catastrophic complication. Although the mechanisms of LST are multifactorial, our laboratory has demonstrated that delayed arterial healing accompanied by poor endothelialisation is the primary pathogical substrate underlying this event. Delayed arterial healing is associated with penetration of necrotic core, long/overlapping stents and bifurcation stenting, especially in flow divider (high shear) regions. Grade V stent fracture is also associated with adverse pathogical findings including LST and restenosis. Moreover, localised hypersensitivity reaction is exclusive to SES as an underlying mechanism of LST, while malapposition secondary to excessive fibrin deposition is associated with PES. Uncovered struts are still identified in both SES and PES with implant duration beyond 12 months, particularly in stents placed for ‘off-label’ indications. In conclusion, the first generation of drug-eluting stents (DES) certainly reduce neointimal growth but this comes at the price of delayed healing.

scholarly journals Very Late Stent Thrombosis 42 Months after Implantation of Sirolimus-Eluting Stent and Discontinuation of Antiplatelet Therapy

2009 ◽  
Vol 2009 ◽  
pp. 1-2 ◽  
Author(s):  
Dirk Sibbing ◽  
Karl-Ludwig Laugwitz ◽  
Lorenz Bott-Flügel ◽  
Jürgen Pache
Keyword(s):  
Stent Thrombosis ◽  
Safety Concern ◽  
Bare Metal Stents ◽  
Drug Eluting Stent ◽  
Metal Stents ◽  
Late Stent Thrombosis ◽  
Stent Deployment ◽  
Very Late Stent Thrombosis ◽  
Drug Eluting ◽  
Sirolimus Eluting Stent

Although safety profiles of sirolimus-eluting stents do not seem to differ in short-to-medium term from those of bare-metal stents, late stent thrombosis after deployment of drug-eluting stents has emerged as a potential safety concern in the era of high-pressure stent implantation. Here, we describe the case of a patient with acute myocardial infarction due to stent thrombosis of a sirolimus-eluting stent 42 months after stent deployment and 5 weeks after discontinuation of aspirin treatment. To the best of our knowledge, this is one of the most delayed cases of sirolimus-eluting stent thrombosis described so far. The case emphasizes the potential risk that late stent thrombosis can unpredictably occur at any time point after drug-eluting stent deployment.

Risk reduction strategies: coronary revascularization before non-cardiac surgery

ESC CardioMed ◽  
2018 ◽  
pp. 2659-2663
Author(s):  
Fabio Rigamonti ◽  
Marco Roffi
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Cardiac Surgery ◽  
Myocardial Revascularization ◽  
Bare Metal Stents ◽  
Coronary Intervention ◽  
Drug Eluting Stent ◽  
Metal Stents ◽  
Percutaneous Coronary ◽  
Reduction Strategies ◽  
Drug Eluting

An individualized, stepwise patient evaluation based on the degree of urgency of non-cardiac surgery, functional capacity, clinical presentation, and estimated cardiovascular stress related to surgery is recommended in order to assess the perioperative cardiovascular risk and optimize management. Myocardial ischaemia in the context of non-cardiac surgery may be related to acute coronary syndromes secondary to coronary plaque rupture or prolonged myocardial oxygen supply–demand imbalance. Randomized controlled trials have failed to show a benefit of routine preoperative prophylactic myocardial revascularization. Preoperative coronary angiography and, if appropriate, myocardial revascularization may be considered before high-risk surgery depending on symptom status and extent of ischaemia on non-invasive imaging. In patients requiring percutaneous coronary intervention, guidelines recommend new-generation drug-eluting stents over bare-metal stents, though randomized data are absent. While the minimal delay for a safe surgery following drug-eluting stent implantation remains to be defined, a time window of 5–6 weeks between percutaneous coronary intervention and surgery appears to be adequate in patients who cannot wait longer.

In-stent restenosis in the drug-eluting stent era

2018 ◽  
pp. 453-472
Author(s):  
Jaya Chandrasekhar ◽  
Adriano Caixeta ◽  
Philippe Généreux ◽  
George Dangas ◽  
Roxana Mehran
Keyword(s):  
Low Frequency ◽  
Bare Metal Stents ◽  
Coronary Intervention ◽  
Drug Eluting Stent ◽  
Metal Stents ◽  
Pharmacological Agents ◽  
Stent Restenosis ◽  
Drug Eluting ◽  
In Stent Restenosis

Since the inception of percutaneous coronary intervention, restenosis has been considered a significant problem. Although drug-eluting stents (DES) have reduced rates of in-stent restenosis (ISR) compared with bare metal stents across all lesion subsets, ISR has not been abolished. DES efficacy has been limited by suboptimal polymer biocompatibility, efficacy of pharmacological agents, in vivo pharmacokinetic properties, and local drug resistance and toxicity. While the first two DES to be manufactured (sirolimus- and paclitaxel-eluting stents) have the longest clinical follow-up, extensive data are now also available on zotarolimus- and everolimus-eluting stents. The uptake of biolimus-eluting stents has recently increased in clinical practice. Although the low frequency of DES ISR makes it difficult to investigate this condition fully, many studies have examined the mechanism, incidence, predictors, and optimal treatment of DES restenosis. This review discusses the data relevant to DES restenosis and the perspective on the current treatment of this condition.

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