Predictors of coronary stent thrombosis: Difference between revisions

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'''Associate Editor-in-Chief:''' Smita Kohli, M.D.
'''Associate Editor-in-Chief:''' Smita Kohli, M.D.; [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.
 
{{EH}}


==Overview==
==Overview==
A number of clinical, angiographic, and procedural factors predispose to the occurrence of stent thrombosis. Predictors of stent thrombosis can be classified into anatomic variables, procedure related variables and clinical variables. A new entity which has been recently recognised and is being increasingly studied in relation to stent thrombosis is hyporesponsiveness to antiplatelet agents.
A number of clinical, angiographic, and procedural factors predispose to the occurrence of [[stent thrombosis]]. Predictors of stent thrombosis can be classified into anatomic variables, procedure related variables and clinical variables. A new entity which has been recently recognised and is being increasingly studied in relation to stent thrombosis is hyporesponsiveness to antiplatelet agents.
 


'''Procedure related variables:'''
'''Procedure related variables:'''
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'''Anatomic variables:'''
'''Anatomic variables:'''
Lesion-specific factors that increase the likelihood of stent thrombosis include a residual dissection at the margin of the stent, impaired flow into or out of the stent, small stent diameters (<3 mm), long stent lengths, and treatment of an acute myocardial infarction<ref name="pmid18371472">{{cite journal |author=Rinaldi MJ, Kirtane AJ, Piana RN, ''et al.'' |title=Clinical, procedural, and pharmacologic correlates of acute and subacute stent thrombosis: results of a multicenter case-control study with 145 thrombosis events |journal=Am. Heart J. |volume=155 |issue=4 |pages=654–60 |year=2008 |month=April |pmid=18371472 |doi=10.1016/j.ahj.2007.11.028 |url=}}</ref>.
Lesion-specific factors that increase the likelihood of stent thrombosis include a residual dissection at the margin of the stent, impaired flow into or out of the stent, small stent diameters (<3 mm), long stent lengths, and treatment of an acute [[myocardial infarction]]<ref name="pmid18371472">{{cite journal |author=Rinaldi MJ, Kirtane AJ, Piana RN, ''et al.'' |title=Clinical, procedural, and pharmacologic correlates of acute and subacute stent thrombosis: results of a multicenter case-control study with 145 thrombosis events |journal=Am. Heart J. |volume=155 |issue=4 |pages=654–60 |year=2008 |month=April |pmid=18371472 |doi=10.1016/j.ahj.2007.11.028 |url=}}</ref>.


'''Clinical variables:'''
'''Clinical variables:'''
Clinical variables include acute myocardial infarction, clopidogrel noncompliance and discontinuation, hyporesponsiveness to antiplatelet agents, higher baseline platelet count, diabetes mellitus, renal failure, congestive heart failure, prior radiation brachytherapy<ref name="pmid18371472">{{cite journal |author=Rinaldi MJ, Kirtane AJ, Piana RN, ''et al.'' |title=Clinical, procedural, and pharmacologic correlates of acute and subacute stent thrombosis: results of a multicenter case-control study with 145 thrombosis events |journal=Am. Heart J. |volume=155 |issue=4 |pages=654–60 |year=2008 |month=April |pmid=18371472 |doi=10.1016/j.ahj.2007.11.028 |url=}}</ref><ref name="pmid15870416">{{cite journal |author=Iakovou I, Schmidt T, Bonizzoni E, ''et al.'' |title=Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents |journal=JAMA |volume=293 |issue=17 |pages=2126–30 |year=2005 |month=May |pmid=15870416 |doi=10.1001/jama.293.17.2126 |url=}}</ref>.  
Clinical variables include acute [[myocardial infarction]], [[clopidogrel]] noncompliance and discontinuation, hyporesponsiveness to antiplatelet agents, higher baseline platelet count, [[diabetes mellitus]], [[renal failure]], [[congestive heart failure]], prior radiation [[brachytherapy]]<ref name="pmid18371472">{{cite journal |author=Rinaldi MJ, Kirtane AJ, Piana RN, ''et al.'' |title=Clinical, procedural, and pharmacologic correlates of acute and subacute stent thrombosis: results of a multicenter case-control study with 145 thrombosis events |journal=Am. Heart J. |volume=155 |issue=4 |pages=654–60 |year=2008 |month=April |pmid=18371472 |doi=10.1016/j.ahj.2007.11.028 |url=}}</ref><ref name="pmid15870416">{{cite journal |author=Iakovou I, Schmidt T, Bonizzoni E, ''et al.'' |title=Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents |journal=JAMA |volume=293 |issue=17 |pages=2126–30 |year=2005 |month=May |pmid=15870416 |doi=10.1001/jama.293.17.2126 |url=}}</ref>.  




In addition to these, stent implantation for off-label indication of both DES and BMS(such as restenotic lesions, bypass graft lesions, left main coronary artery disease, as well as ostial, bifurcated, and totally occluded lesions) has been associated with higher rates of ischemic complications, including stent thrombosis, as compared with standard indications<ref name="pmid17488964">{{cite journal |author=Beohar N, Davidson CJ, Kip KE, ''et al.'' |title=Outcomes and complications associated with off-label and untested use of drug-eluting stents |journal=JAMA |volume=297 |issue=18 |pages=1992–2000 |year=2007 |month=May |pmid=17488964 |doi=10.1001/jama.297.18.1992 |url=}}</ref><ref name="pmid17488965">{{cite journal |author=Win HK, Caldera AE, Maresh K, ''et al.'' |title=Clinical outcomes and stent thrombosis following off-label use of drug-eluting stents |journal=JAMA |volume=297 |issue=18 |pages=2001–9 |year=2007 |month=May |pmid=17488965 |doi=10.1001/jama.297.18.2001 |url=}}</ref>.
In addition to these, stent implantation for off-label indication of both [[DES]] and [[BMS]](such as restenotic lesions, bypass graft lesions, left main coronary artery disease, as well as ostial, bifurcated, and totally occluded lesions) has been associated with higher rates of ischemic complications, including stent thrombosis, as compared with standard indications<ref name="pmid17488964">{{cite journal |author=Beohar N, Davidson CJ, Kip KE, ''et al.'' |title=Outcomes and complications associated with off-label and untested use of drug-eluting stents |journal=JAMA |volume=297 |issue=18 |pages=1992–2000 |year=2007 |month=May |pmid=17488964 |doi=10.1001/jama.297.18.1992 |url=}}</ref><ref name="pmid17488965">{{cite journal |author=Win HK, Caldera AE, Maresh K, ''et al.'' |title=Clinical outcomes and stent thrombosis following off-label use of drug-eluting stents |journal=JAMA |volume=297 |issue=18 |pages=2001–9 |year=2007 |month=May |pmid=17488965 |doi=10.1001/jama.297.18.2001 |url=}}</ref>.
In a case control study of 145 patients with stent thrombosis by Rinaldi et al<ref name="pmid18371472">{{cite journal |author=Rinaldi MJ, Kirtane AJ, Piana RN, ''et al.'' |title=Clinical, procedural, and pharmacologic correlates of acute and subacute stent thrombosis: results of a multicenter case-control study with 145 thrombosis events |journal=Am. Heart J. |volume=155 |issue=4 |pages=654–60 |year=2008 |month=April |pmid=18371472 |doi=10.1016/j.ahj.2007.11.028 |url=}}</ref>, presence of angiographic thrombus prior to stenting, greater total stent length, higher baseline platelet count, acute MI indication, the use of a self expanding or coil stent, and GpIIb-IIIa exposure were identified as the strongest predictors of stent thrombosis.
In a case control study of 145 patients with stent thrombosis by Rinaldi et al<ref name="pmid18371472">{{cite journal |author=Rinaldi MJ, Kirtane AJ, Piana RN, ''et al.'' |title=Clinical, procedural, and pharmacologic correlates of acute and subacute stent thrombosis: results of a multicenter case-control study with 145 thrombosis events |journal=Am. Heart J. |volume=155 |issue=4 |pages=654–60 |year=2008 |month=April |pmid=18371472 |doi=10.1016/j.ahj.2007.11.028 |url=}}</ref>, presence of angiographic thrombus prior to stenting, greater total stent length, higher baseline platelet count, acute MI indication, the use of a self expanding or coil stent, and GpIIb-IIIa exposure were identified as the strongest predictors of stent thrombosis.


In another study by Marroquin et al<ref name="pmid18216354">{{cite journal |author=Marroquin OC, Selzer F, Mulukutla SR, ''et al.'' |title=A comparison of bare-metal and drug-eluting stents for off-label indications |journal=N. Engl. J. Med. |volume=358 |issue=4 |pages=342–52 |year=2008 |month=January |pmid=18216354 |pmc=2761092 |doi=10.1056/NEJMoa0706258 |url=}}</ref> to compare the outcomes in bare-metal versus drug-elting stents for off-label indications showed that one year after intervention, there were no significant differences in the adjusted risk of death or myocardial infarction in patients with drug-eluting stents as compared with those with bare-metal stents. These findings implicate that the poorer outcome observed after stenting for off-label indications are related to patient and lesion characteristics but not to the stent itself. Therefore, large randomized clinical trial are needed to further study the use of DES for off label versus standard indications.
In another study by Marroquin et al<ref name="pmid18216354">{{cite journal |author=Marroquin OC, Selzer F, Mulukutla SR, ''et al.'' |title=A comparison of bare-metal and drug-eluting stents for off-label indications |journal=N. Engl. J. Med. |volume=358 |issue=4 |pages=342–52 |year=2008 |month=January |pmid=18216354 |pmc=2761092 |doi=10.1056/NEJMoa0706258 |url=}}</ref> to compare the outcomes in bare-metal versus drug-elting stents for off-label indications showed that one year after intervention, there were no significant differences in the adjusted risk of death or myocardial infarction in patients with [[drug eluting stent]]s as compared with those with [[bare metal stent]]s. These findings implicate that the poorer outcome observed after stenting for off-label indications are related to patient and lesion characteristics but not to the stent itself. Therefore, large randomized clinical trial are needed to further study the use of DES for off label versus standard indications.


==Risk factors for early and late stent thrombosis==
==Risk factors for early and late stent thrombosis==
#Discontinued [[clopidogrel]]
#Premature discontinuation of [[antiplatelets]]/[[clopidogrel]]<ref name="pmid19371823">{{cite journal| author=van Werkum JW, Heestermans AA, Zomer AC, Kelder JC, Suttorp MJ, Rensing BJ et al.| title=Predictors of coronary stent thrombosis: the Dutch Stent Thrombosis Registry. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 16 | pages= 1399-409 | pmid=19371823 | doi=10.1016/j.jacc.2008.12.055 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19371823  }} </ref><ref name="pmid15870416">{{cite journal| author=Iakovou I, Schmidt T, Bonizzoni E, Ge L, Sangiorgi GM, Stankovic G et al.| title=Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. | journal=JAMA | year= 2005 | volume= 293 | issue= 17 | pages= 2126-30 | pmid=15870416 | doi=10.1001/jama.293.17.2126 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15870416  }} </ref><ref name="pmid16769908">{{cite journal| author=Spertus JA, Kettelkamp R, Vance C, Decker C, Jones PG, Rumsfeld JS et al.| title=Prevalence, predictors, and outcomes of premature discontinuation of thienopyridine therapy after drug-eluting stent placement: results from the PREMIER registry. | journal=Circulation | year= 2006 | volume= 113 | issue= 24 | pages= 2803-9 | pmid=16769908 | doi=10.1161/CIRCULATIONAHA.106.618066 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16769908  }} </ref>
#Abscence/dysfunction of CYP2C19 allele which is required for the conversion of clopidogrel to its active metabolite.
#Abscence/dysfunction of CYP2C19 allele which is required for the conversion of clopidogrel to its active metabolite.<ref name="pmid19463375">{{cite journal| author=Gladding P, Webster M, Zeng I, Farrell H, Stewart J, Ruygrok P et al.| title=The pharmacogenetics and pharmacodynamics of clopidogrel response: an analysis from the PRINC (Plavix Response in Coronary Intervention) trial. | journal=JACC Cardiovasc Interv | year= 2008 | volume= 1 | issue= 6 | pages= 620-7 | pmid=19463375 | doi=10.1016/j.jcin.2008.09.008 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19463375  }} </ref>
#Incomplete opposition of the stent
#Improper opposition of the stent or undersized stent<ref name="pmid19371823">{{cite journal| author=van Werkum JW, Heestermans AA, Zomer AC, Kelder JC, Suttorp MJ, Rensing BJ et al.| title=Predictors of coronary stent thrombosis: the Dutch Stent Thrombosis Registry. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 16 | pages= 1399-409 | pmid=19371823 | doi=10.1016/j.jacc.2008.12.055 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19371823  }} </ref><ref name="pmid7882474">{{cite journal| author=Colombo A, Hall P, Nakamura S, Almagor Y, Maiello L, Martini G et al.| title=Intracoronary stenting without anticoagulation accomplished with intravascular ultrasound guidance. | journal=Circulation | year= 1995 | volume= 91 | issue= 6 | pages= 1676-88 | pmid=7882474 | doi= | pmc= | url= }} </ref>
#Length of the stent- greater the length, higher the risk
#Length of the stent- greater the length, higher the risk<ref name="pmid11306525">{{cite journal| author=Cutlip DE, Baim DS, Ho KK, Popma JJ, Lansky AJ, Cohen DJ et al.| title=Stent thrombosis in the modern era: a pooled analysis of multicenter coronary stent clinical trials. | journal=Circulation | year= 2001 | volume= 103 | issue= 15 | pages= 1967-71 | pmid=11306525 | doi= | pmc= | url= }} </ref>
#Malignancy
#Malignancy<ref name="pmid19371823">{{cite journal| author=van Werkum JW, Heestermans AA, Zomer AC, Kelder JC, Suttorp MJ, Rensing BJ et al.| title=Predictors of coronary stent thrombosis: the Dutch Stent Thrombosis Registry. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 16 | pages= 1399-409 | pmid=19371823 | doi=10.1016/j.jacc.2008.12.055 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19371823  }} </ref>
#[[Cocaine]] use
#[[Cocaine]] use<ref name="pmid17525956">{{cite journal| author=Lemos PA| title=Hidden drugs, hidden risks--is cocaine use a new risk factor for stent thrombosis? | journal=Catheter Cardiovasc Interv | year= 2007 | volume= 69 | issue= 7 | pages= 959-60 | pmid=17525956 | doi=10.1002/ccd.21239 | pmc= | url= }} </ref><ref name="pmid17584570">{{cite journal| author=McKee SA, Applegate RJ, Hoyle JR, Sacrinty MT, Kutcher MA, Sane DC| title=Cocaine use is associated with an increased risk of stent thrombosis after percutaneous coronary intervention. | journal=Am Heart J | year= 2007 | volume= 154 | issue= 1 | pages= 159-64 | pmid=17584570 | doi=10.1016/j.ahj.2007.04.004 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17584570  }} </ref>
#Small caliber of the vessels
#Small caliber of the vessels<ref name="pmid11306525">{{cite journal| author=Cutlip DE, Baim DS, Ho KK, Popma JJ, Lansky AJ, Cohen DJ et al.| title=Stent thrombosis in the modern era: a pooled analysis of multicenter coronary stent clinical trials. | journal=Circulation | year= 2001 | volume= 103 | issue= 15 | pages= 1967-71 | pmid=11306525 | doi= | pmc= | url= }} </ref>
#[[TIMI flow grade]]<3 post [[PCI]]
#Slow intra coronary flow post [[PCI]]<ref name="pmid8996288">{{cite journal| author=Moussa I, Di Mario C, Reimers B, Akiyama T, Tobis J, Colombo A| title=Subacute stent thrombosis in the era of intravascular ultrasound-guided coronary stenting without anticoagulation: frequency, predictors and clinical outcome. | journal=J Am Coll Cardiol | year= 1997 | volume= 29 | issue= 1 | pages= 6-12 | pmid=8996288 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8996288  }} </ref>
#Bifurcation lesion
#Bifurcation lesion<ref name="pmid15870416">{{cite journal| author=Iakovou I, Schmidt T, Bonizzoni E, Ge L, Sangiorgi GM, Stankovic G et al.| title=Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. | journal=JAMA | year= 2005 | volume= 293 | issue= 17 | pages= 2126-30 | pmid=15870416 | doi=10.1001/jama.293.17.2126 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15870416  }} </ref>
#Inadequate periprocedural [[anticoagulation]]
#Inadequate periprocedural [[anticoagulation]]<ref name="pmid17224480">{{cite journal| author=Grines CL, Bonow RO, Casey DE, Gardner TJ, Lockhart PB, Moliterno DJ et al.| title=Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. | journal=Circulation | year= 2007 | volume= 115 | issue= 6 | pages= 813-8 | pmid=17224480 | doi=10.1161/CIRCULATIONAHA.106.180944 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17224480  }} </ref>
#Emergent stent placement
#Low [[ejection fraction]] (<30%)<ref name="pmid8996288">{{cite journal| author=Moussa I, Di Mario C, Reimers B, Akiyama T, Tobis J, Colombo A| title=Subacute stent thrombosis in the era of intravascular ultrasound-guided coronary stenting without anticoagulation: frequency, predictors and clinical outcome. | journal=J Am Coll Cardiol | year= 1997 | volume= 29 | issue= 1 | pages= 6-12 | pmid=8996288 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8996288  }} </ref><ref name="pmid15870416">{{cite journal| author=Iakovou I, Schmidt T, Bonizzoni E, Ge L, Sangiorgi GM, Stankovic G et al.| title=Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. | journal=JAMA | year= 2005 | volume= 293 | issue= 17 | pages= 2126-30 | pmid=15870416 | doi=10.1001/jama.293.17.2126 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15870416  }} </ref><ref name="pmid19371823">{{cite journal| author=van Werkum JW, Heestermans AA, Zomer AC, Kelder JC, Suttorp MJ, Rensing BJ et al.| title=Predictors of coronary stent thrombosis: the Dutch Stent Thrombosis Registry. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 16 | pages= 1399-409 | pmid=19371823 | doi=10.1016/j.jacc.2008.12.055 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19371823  }} </ref>
#Left [[ventricular dysfunction]]
#Nonionic contrast media<ref name="pmid11207080">{{cite journal| author=Scheller B, Hennen B, Pohl A, Schieffer H, Markwirth T| title=Acute and subacute stent occlusion; risk-reduction by ionic contrast media. | journal=Eur Heart J | year= 2001 | volume= 22 | issue= 5 | pages= 385-91 | pmid=11207080 | doi=10.1053/euhj.2000.2319 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11207080  }} </ref>
#Nonionic contrast media
#Prior [[brachytherapy]]
#Prior [[brachytherapy]]
#small stent area on [[intracoronary ultrasound]]
#Small stent area on [[intracoronary ultrasound]]<ref name="pmid8181126">{{cite journal| author=Nakamura S, Colombo A, Gaglione A, Almagor Y, Goldberg SL, Maiello L et al.| title=Intracoronary ultrasound observations during stent implantation. | journal=Circulation | year= 1994 | volume= 89 | issue= 5 | pages= 2026-34 | pmid=8181126 | doi= | pmc= | url= }} </ref>
#Residual plaque/thrombus/dissection after stent placement
#Residual [[plaque]]/[[thrombus]]/[[dissection]] after stent placement<ref name="pmid12821553">{{cite journal| author=Cheneau E, Leborgne L, Mintz GS, Kotani J, Pichard AD, Satler LF et al.| title=Predictors of subacute stent thrombosis: results of a systematic intravascular ultrasound study. | journal=Circulation | year= 2003 | volume= 108 | issue= 1 | pages= 43-7 | pmid=12821553 | doi=10.1161/01.CIR.0000078636.71728.40 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12821553  }} </ref><ref name="pmid8996288">{{cite journal| author=Moussa I, Di Mario C, Reimers B, Akiyama T, Tobis J, Colombo A| title=Subacute stent thrombosis in the era of intravascular ultrasound-guided coronary stenting without anticoagulation: frequency, predictors and clinical outcome. | journal=J Am Coll Cardiol | year= 1997 | volume= 29 | issue= 1 | pages= 6-12 | pmid=8996288 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8996288  }} </ref><ref name="pmid11306525">{{cite journal| author=Cutlip DE, Baim DS, Ho KK, Popma JJ, Lansky AJ, Cohen DJ et al.| title=Stent thrombosis in the modern era: a pooled analysis of multicenter coronary stent clinical trials. | journal=Circulation | year= 2001 | volume= 103 | issue= 15 | pages= 1967-71 | pmid=11306525 | doi= | pmc= | url= }} </ref>
#CAD ≥50% proximal of culprit lesion
#[[CAD]] ≥50% proximal of culprit lesion<ref name="pmid19371823">{{cite journal| author=van Werkum JW, Heestermans AA, Zomer AC, Kelder JC, Suttorp MJ, Rensing BJ et al.| title=Predictors of coronary stent thrombosis: the Dutch Stent Thrombosis Registry. | journal=J Am Coll Cardiol | year= 2009 | volume= 53 | issue= 16 | pages= 1399-409 | pmid=19371823 | doi=10.1016/j.jacc.2008.12.055 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19371823  }} </ref>
#[[Chronic kidney disease]]<ref name="pmid15870416">{{cite journal| author=Iakovou I, Schmidt T, Bonizzoni E, Ge L, Sangiorgi GM, Stankovic G et al.| title=Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. | journal=JAMA | year= 2005 | volume= 293 | issue= 17 | pages= 2126-30 | pmid=15870416 | doi=10.1001/jama.293.17.2126 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15870416  }} </ref><ref name="pmid16490815">{{cite journal| author=Kuchulakanti PK, Chu WW, Torguson R, Ohlmann P, Rha SW, Clavijo LC et al.| title=Correlates and long-term outcomes of angiographically proven stent thrombosis with sirolimus- and paclitaxel-eluting stents. | journal=Circulation | year= 2006 | volume= 113 | issue= 8 | pages= 1108-13 | pmid=16490815 | doi=10.1161/CIRCULATIONAHA.105.600155 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16490815  }} </ref>
#[[Diabetes mellitus]]<ref name="pmid18804739">{{cite journal| author=Wenaweser P, Daemen J, Zwahlen M, van Domburg R, Jüni P, Vaina S et al.| title=Incidence and correlates of drug-eluting stent thrombosis in routine clinical practice. 4-year results from a large 2-institutional cohort study. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 14 | pages= 1134-40 | pmid=18804739 | doi=10.1016/j.jacc.2008.07.006 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18804739  }} </ref><ref name="pmid15870416">{{cite journal| author=Iakovou I, Schmidt T, Bonizzoni E, Ge L, Sangiorgi GM, Stankovic G et al.| title=Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. | journal=JAMA | year= 2005 | volume= 293 | issue= 17 | pages= 2126-30 | pmid=15870416 | doi=10.1001/jama.293.17.2126 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15870416  }} </ref>
#Black race<ref name="pmid20805432">{{cite journal| author=Collins SD, Torguson R, Gaglia MA, Lemesle G, Syed AI, Ben-Dor I et al.| title=Does black ethnicity influence the development of stent thrombosis in the drug-eluting stent era? | journal=Circulation | year= 2010 | volume= 122 | issue= 11 | pages= 1085-90 | pmid=20805432 | doi=10.1161/CIRCULATIONAHA.109.907998 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20805432  }} </ref>
#Elevated [[C-reactive protein]] levels<ref name="pmid19884467">{{cite journal| author=Park DW, Yun SC, Lee JY, Kim WJ, Kang SJ, Lee SW et al.| title=C-reactive protein and the risk of stent thrombosis and cardiovascular events after drug-eluting stent implantation. | journal=Circulation | year= 2009 | volume= 120 | issue= 20 | pages= 1987-95 | pmid=19884467 | doi=10.1161/CIRCULATIONAHA.109.876763 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19884467  }} </ref>
#Hypersensitivity to stents<ref name="pmid16386683">{{cite journal| author=Nebeker JR, Virmani R, Bennett CL, Hoffman JM, Samore MH, Alvarez J et al.| title=Hypersensitivity cases associated with drug-eluting coronary stents: a review of available cases from the Research on Adverse Drug Events and Reports (RADAR) project. | journal=J Am Coll Cardiol | year= 2006 | volume= 47 | issue= 1 | pages= 175-81 | pmid=16386683 | doi=10.1016/j.jacc.2005.07.071 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16386683  }} </ref>
#Young age<ref name="pmid18804739">{{cite journal| author=Wenaweser P, Daemen J, Zwahlen M, van Domburg R, Jüni P, Vaina S et al.| title=Incidence and correlates of drug-eluting stent thrombosis in routine clinical practice. 4-year results from a large 2-institutional cohort study. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 14 | pages= 1134-40 | pmid=18804739 | doi=10.1016/j.jacc.2008.07.006 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18804739  }} </ref>
#[[Paclitaxel]]-eluting stent implantation<ref name="pmid18804739">{{cite journal| author=Wenaweser P, Daemen J, Zwahlen M, van Domburg R, Jüni P, Vaina S et al.| title=Incidence and correlates of drug-eluting stent thrombosis in routine clinical practice. 4-year results from a large 2-institutional cohort study. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 14 | pages= 1134-40 | pmid=18804739 | doi=10.1016/j.jacc.2008.07.006 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18804739  }} </ref>
#Multivessel disease<ref name="pmid19228612">{{cite journal| author=Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ et al.| title=Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. | journal=N Engl J Med | year= 2009 | volume= 360 | issue= 10 | pages= 961-72 | pmid=19228612 | doi=10.1056/NEJMoa0804626 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19228612  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19620153 Review in: Ann Intern Med. 2009 Jul 21;151(2):JC1-8, JC1-9] </ref>
#[[Acute coronary syndrome]] at presentation<ref name="pmid17321312">{{cite journal| author=Daemen J, Wenaweser P, Tsuchida K, Abrecht L, Vaina S, Morger C et al.| title=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. | journal=Lancet | year= 2007 | volume= 369 | issue= 9562 | pages= 667-78 | pmid=17321312 | doi=10.1016/S0140-6736(07)60314-6 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17321312  }} </ref>
 
==Risk factors for very late stent thrombosis==
#Ongoing vessel inflammation<ref name="pmid16814667">{{cite journal| author=Joner M, Finn AV, Farb A, Mont EK, Kolodgie FD, Ladich E et al.| title=Pathology of drug-eluting stents in humans: delayed healing and late thrombotic risk. | journal=J Am Coll Cardiol | year= 2006 | volume= 48 | issue= 1 | pages= 193-202 | pmid=16814667 | doi=10.1016/j.jacc.2006.03.042 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16814667  }} </ref>
#Delayed neointimal coverage which is usually seen with [[DES]] when compared to [[BMS]]<ref name="pmid17438147">{{cite journal| author=Finn AV, Joner M, Nakazawa G, Kolodgie F, Newell J, John MC et al.| title=Pathological correlates of late drug-eluting stent thrombosis: strut coverage as a marker of endothelialization. | journal=Circulation | year= 2007 | volume= 115 | issue= 18 | pages= 2435-41 | pmid=17438147 | doi=10.1161/CIRCULATIONAHA.107.693739 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17438147  }} </ref><ref name="pmid16814667">{{cite journal| author=Joner M, Finn AV, Farb A, Mont EK, Kolodgie FD, Ladich E et al.| title=Pathology of drug-eluting stents in humans: delayed healing and late thrombotic risk. | journal=J Am Coll Cardiol | year= 2006 | volume= 48 | issue= 1 | pages= 193-202 | pmid=16814667 | doi=10.1016/j.jacc.2006.03.042 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16814667  }} </ref>


==References==
==References==
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{{reflist|2}}

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Overview

A number of clinical, angiographic, and procedural factors predispose to the occurrence of stent thrombosis. Predictors of stent thrombosis can be classified into anatomic variables, procedure related variables and clinical variables. A new entity which has been recently recognised and is being increasingly studied in relation to stent thrombosis is hyporesponsiveness to antiplatelet agents.

Procedure related variables: Procedure related variables include stent underexpansion, margin dissections, incomplete wall apposition, residual inflow and outflow disease, overlapping stent, polymer materials and use of self expanding or coil stents[1].

Anatomic variables: Lesion-specific factors that increase the likelihood of stent thrombosis include a residual dissection at the margin of the stent, impaired flow into or out of the stent, small stent diameters (<3 mm), long stent lengths, and treatment of an acute myocardial infarction[1].

Clinical variables: Clinical variables include acute myocardial infarction, clopidogrel noncompliance and discontinuation, hyporesponsiveness to antiplatelet agents, higher baseline platelet count, diabetes mellitus, renal failure, congestive heart failure, prior radiation brachytherapy[1][2].


In addition to these, stent implantation for off-label indication of both DES and BMS(such as restenotic lesions, bypass graft lesions, left main coronary artery disease, as well as ostial, bifurcated, and totally occluded lesions) has been associated with higher rates of ischemic complications, including stent thrombosis, as compared with standard indications[3][4]. In a case control study of 145 patients with stent thrombosis by Rinaldi et al[1], presence of angiographic thrombus prior to stenting, greater total stent length, higher baseline platelet count, acute MI indication, the use of a self expanding or coil stent, and GpIIb-IIIa exposure were identified as the strongest predictors of stent thrombosis.

In another study by Marroquin et al[5] to compare the outcomes in bare-metal versus drug-elting stents for off-label indications showed that one year after intervention, there were no significant differences in the adjusted risk of death or myocardial infarction in patients with drug eluting stents as compared with those with bare metal stents. These findings implicate that the poorer outcome observed after stenting for off-label indications are related to patient and lesion characteristics but not to the stent itself. Therefore, large randomized clinical trial are needed to further study the use of DES for off label versus standard indications.

Risk factors for early and late stent thrombosis

  1. Premature discontinuation of antiplatelets/clopidogrel[6][2][7]
  2. Abscence/dysfunction of CYP2C19 allele which is required for the conversion of clopidogrel to its active metabolite.[8]
  3. Improper opposition of the stent or undersized stent[6][9]
  4. Length of the stent- greater the length, higher the risk[10]
  5. Malignancy[6]
  6. Cocaine use[11][12]
  7. Small caliber of the vessels[10]
  8. Slow intra coronary flow post PCI[13]
  9. Bifurcation lesion[2]
  10. Inadequate periprocedural anticoagulation[14]
  11. Low ejection fraction (<30%)[13][2][6]
  12. Nonionic contrast media[15]
  13. Prior brachytherapy
  14. Small stent area on intracoronary ultrasound[16]
  15. Residual plaque/thrombus/dissection after stent placement[17][13][10]
  16. CAD ≥50% proximal of culprit lesion[6]
  17. Chronic kidney disease[2][18]
  18. Diabetes mellitus[19][2]
  19. Black race[20]
  20. Elevated C-reactive protein levels[21]
  21. Hypersensitivity to stents[22]
  22. Young age[19]
  23. Paclitaxel-eluting stent implantation[19]
  24. Multivessel disease[23]
  25. Acute coronary syndrome at presentation[24]

Risk factors for very late stent thrombosis

  1. Ongoing vessel inflammation[25]
  2. Delayed neointimal coverage which is usually seen with DES when compared to BMS[26][25]

References

  1. ↑ 1.0 1.1 1.2 1.3 Rinaldi MJ, Kirtane AJ, Piana RN; et al. (2008). "Clinical, procedural, and pharmacologic correlates of acute and subacute stent thrombosis: results of a multicenter case-control study with 145 thrombosis events". Am. Heart J. 155 (4): 654–60. doi:10.1016/j.ahj.2007.11.028. PMID 18371472. Unknown parameter |month= ignored (help)
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Iakovou I, Schmidt T, Bonizzoni E; et al. (2005). "Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents". JAMA. 293 (17): 2126–30. doi:10.1001/jama.293.17.2126. PMID 15870416. Unknown parameter |month= ignored (help)
  3. ↑ Beohar N, Davidson CJ, Kip KE; et al. (2007). "Outcomes and complications associated with off-label and untested use of drug-eluting stents". JAMA. 297 (18): 1992–2000. doi:10.1001/jama.297.18.1992. PMID 17488964. Unknown parameter |month= ignored (help)
  4. ↑ Win HK, Caldera AE, Maresh K; et al. (2007). "Clinical outcomes and stent thrombosis following off-label use of drug-eluting stents". JAMA. 297 (18): 2001–9. doi:10.1001/jama.297.18.2001. PMID 17488965. Unknown parameter |month= ignored (help)
  5. ↑ Marroquin OC, Selzer F, Mulukutla SR; et al. (2008). "A comparison of bare-metal and drug-eluting stents for off-label indications". N. Engl. J. Med. 358 (4): 342–52. doi:10.1056/NEJMoa0706258. PMC 2761092. PMID 18216354. Unknown parameter |month= ignored (help)
  6. ↑ 6.0 6.1 6.2 6.3 6.4 van Werkum JW, Heestermans AA, Zomer AC, Kelder JC, Suttorp MJ, Rensing BJ; et al. (2009). "Predictors of coronary stent thrombosis: the Dutch Stent Thrombosis Registry". J Am Coll Cardiol. 53 (16): 1399–409. doi:10.1016/j.jacc.2008.12.055. PMID 19371823.
  7. ↑ Spertus JA, Kettelkamp R, Vance C, Decker C, Jones PG, Rumsfeld JS; et al. (2006). "Prevalence, predictors, and outcomes of premature discontinuation of thienopyridine therapy after drug-eluting stent placement: results from the PREMIER registry". Circulation. 113 (24): 2803–9. doi:10.1161/CIRCULATIONAHA.106.618066. PMID 16769908.
  8. ↑ Gladding P, Webster M, Zeng I, Farrell H, Stewart J, Ruygrok P; et al. (2008). "The pharmacogenetics and pharmacodynamics of clopidogrel response: an analysis from the PRINC (Plavix Response in Coronary Intervention) trial". JACC Cardiovasc Interv. 1 (6): 620–7. doi:10.1016/j.jcin.2008.09.008. PMID 19463375.
  9. ↑ Colombo A, Hall P, Nakamura S, Almagor Y, Maiello L, Martini G; et al. (1995). "Intracoronary stenting without anticoagulation accomplished with intravascular ultrasound guidance". Circulation. 91 (6): 1676–88. PMID 7882474.
  10. ↑ 10.0 10.1 10.2 Cutlip DE, Baim DS, Ho KK, Popma JJ, Lansky AJ, Cohen DJ; et al. (2001). "Stent thrombosis in the modern era: a pooled analysis of multicenter coronary stent clinical trials". Circulation. 103 (15): 1967–71. PMID 11306525.
  11. ↑ Lemos PA (2007). "Hidden drugs, hidden risks--is cocaine use a new risk factor for stent thrombosis?". Catheter Cardiovasc Interv. 69 (7): 959–60. doi:10.1002/ccd.21239. PMID 17525956.
  12. ↑ McKee SA, Applegate RJ, Hoyle JR, Sacrinty MT, Kutcher MA, Sane DC (2007). "Cocaine use is associated with an increased risk of stent thrombosis after percutaneous coronary intervention". Am Heart J. 154 (1): 159–64. doi:10.1016/j.ahj.2007.04.004. PMID 17584570.
  13. ↑ 13.0 13.1 13.2 Moussa I, Di Mario C, Reimers B, Akiyama T, Tobis J, Colombo A (1997). "Subacute stent thrombosis in the era of intravascular ultrasound-guided coronary stenting without anticoagulation: frequency, predictors and clinical outcome". J Am Coll Cardiol. 29 (1): 6–12. PMID 8996288.
  14. ↑ Grines CL, Bonow RO, Casey DE, Gardner TJ, Lockhart PB, Moliterno DJ; et al. (2007). "Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians". Circulation. 115 (6): 813–8. doi:10.1161/CIRCULATIONAHA.106.180944. PMID 17224480.
  15. ↑ Scheller B, Hennen B, Pohl A, Schieffer H, Markwirth T (2001). "Acute and subacute stent occlusion; risk-reduction by ionic contrast media". Eur Heart J. 22 (5): 385–91. doi:10.1053/euhj.2000.2319. PMID 11207080.
  16. ↑ Nakamura S, Colombo A, Gaglione A, Almagor Y, Goldberg SL, Maiello L; et al. (1994). "Intracoronary ultrasound observations during stent implantation". Circulation. 89 (5): 2026–34. PMID 8181126.
  17. ↑ Cheneau E, Leborgne L, Mintz GS, Kotani J, Pichard AD, Satler LF; et al. (2003). "Predictors of subacute stent thrombosis: results of a systematic intravascular ultrasound study". Circulation. 108 (1): 43–7. doi:10.1161/01.CIR.0000078636.71728.40. PMID 12821553.
  18. ↑ Kuchulakanti PK, Chu WW, Torguson R, Ohlmann P, Rha SW, Clavijo LC; et al. (2006). "Correlates and long-term outcomes of angiographically proven stent thrombosis with sirolimus- and paclitaxel-eluting stents". Circulation. 113 (8): 1108–13. doi:10.1161/CIRCULATIONAHA.105.600155. PMID 16490815.
  19. ↑ 19.0 19.1 19.2 Wenaweser P, Daemen J, Zwahlen M, van Domburg R, Jüni P, Vaina S; et al. (2008). "Incidence and correlates of drug-eluting stent thrombosis in routine clinical practice. 4-year results from a large 2-institutional cohort study". J Am Coll Cardiol. 52 (14): 1134–40. doi:10.1016/j.jacc.2008.07.006. PMID 18804739.
  20. ↑ Collins SD, Torguson R, Gaglia MA, Lemesle G, Syed AI, Ben-Dor I; et al. (2010). "Does black ethnicity influence the development of stent thrombosis in the drug-eluting stent era?". Circulation. 122 (11): 1085–90. doi:10.1161/CIRCULATIONAHA.109.907998. PMID 20805432.
  21. ↑ Park DW, Yun SC, Lee JY, Kim WJ, Kang SJ, Lee SW; et al. (2009). "C-reactive protein and the risk of stent thrombosis and cardiovascular events after drug-eluting stent implantation". Circulation. 120 (20): 1987–95. doi:10.1161/CIRCULATIONAHA.109.876763. PMID 19884467.
  22. ↑ Nebeker JR, Virmani R, Bennett CL, Hoffman JM, Samore MH, Alvarez J; et al. (2006). "Hypersensitivity cases associated with drug-eluting coronary stents: a review of available cases from the Research on Adverse Drug Events and Reports (RADAR) project". J Am Coll Cardiol. 47 (1): 175–81. doi:10.1016/j.jacc.2005.07.071. PMID 16386683.
  23. ↑ Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ; et al. (2009). "Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease". N Engl J Med. 360 (10): 961–72. doi:10.1056/NEJMoa0804626. PMID 19228612. Review in: Ann Intern Med. 2009 Jul 21;151(2):JC1-8, JC1-9
  24. ↑ Daemen J, Wenaweser P, Tsuchida K, Abrecht L, Vaina S, Morger C; et al. (2007). "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. 369 (9562): 667–78. doi:10.1016/S0140-6736(07)60314-6. PMID 17321312.
  25. ↑ 25.0 25.1 Joner M, Finn AV, Farb A, Mont EK, Kolodgie FD, Ladich E; et al. (2006). "Pathology of drug-eluting stents in humans: delayed healing and late thrombotic risk". J Am Coll Cardiol. 48 (1): 193–202. doi:10.1016/j.jacc.2006.03.042. PMID 16814667.
  26. ↑ Finn AV, Joner M, Nakazawa G, Kolodgie F, Newell J, John MC; et al. (2007). "Pathological correlates of late drug-eluting stent thrombosis: strut coverage as a marker of endothelialization". Circulation. 115 (18): 2435–41. doi:10.1161/CIRCULATIONAHA.107.693739. PMID 17438147.
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