Intraprocedural stent thrombosis
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Synonyms and keywords: IPST
Overview
Intraprocedural stent thrombosis (IPST) is the formation of a new, increasing, or reappearing occlusive or non-occlusive thrombus of grade ≤2 that occurs before the completion of the PCI procedure, and is specifically located within the recently deployed stent or immediately adjacent to it.[1] It is considered a rare subset of IPTE. Although uncommon, it has been strongly associated with subsequent unfavorable periprocedural outcome.[2]
Pathophysiology
IPST can occur with bare metal stents and DES. Several theories suggest possible explanation to IPST in DES. DES characteristics, such as drug-induced thrombogenicity, whether using sirolimus or paclitaxel, and its in-vitro platelet aggregation effects[3] along with its remarkable lipophilic bioavailability within the coronary milieu,[4] stent platform effect,[5] polymer coating material,[5] and open-cell stent design all seem plausible hypotheses that nonetheless require further validation. Operator-dependent factors, such as adequate stent placement have also been postulated.[6]
Epidemiology and Demographics
- The frequency of occurrence currently ranges between 0.5 – 1.7% of all PCI procedures.
- IPST occurred in 0.7% of PCI when frame-by-frame analysis was done for 6591 patients enrolled in the ACUITY and HORIZONS-AMI (Harmonizing Outcomes With Revascularization And Stents In Acute Myocardial Infarction) trials.[2]
- Similarly, an IPST rate of 1.2% was document in another study in 2013 following enrollment of 1901 patients.[7]
- The incidence of IPST was 0.7% in two other studies, the first of which reviewed the frequency of IPST in 1320 patients less than 75 years old undergoing PCI with first generation DES and whereas the second study enrolled 670 patients undergoing elective DES.[6][8]
- Finally, 1.7% of 181 patients had IPST when evaluating DES implantation in bifurcation lesions using “crush technique” in 2005.[9]
Risk Factors
Interestingly, conventional risk factors and correlates of early and late postprocedural stent thrombosis do not seem to be the same as those for IPST.
Associated Factors
Although data in the literature is still conflicting, IPST has been variably correlated to several parameters:
- ST-segment elevation MI (STEMI) at presentation[10]
- High white blood cell count[10]
- Implantation of bare metal stents rather than drug-eluting stents (DES)[10]
- Increased total stent length: stent sizes are commonly lengthier in DES[6]
- Increased thrombus size: baseline thrombus was visible in 56.5% of cases with IPST vs. only 12.3% of cases with no IPST[1]
- Thrombotic lesions[10]
- Lesion location at bifurcations: increase of IPST risk from 0.5% to 1.3%[8]
- Increased diameter of stenosis: average degree of stenosis was 81.58% in patients with IPST vs. 70.23% in patients without IPST[1]
- “Crush” bifurcation stenting[11]
- Worse minimum pre-PCI TIMI flow: TIMI flow grade 0 or TIMI flow grade 1[1]
- Bivalirudin monotherapy: patients who receive treatment with elective glycoprotein IIb/IIIa inhibitors rather than bail-out use seem to be much less likely to experience IPST[6][10]
Natural History, Complications and Prognosis
IPST significantly reduces the overall success rate of PCI, as measured by frequency of achieving TIMI flow grade 3 at the end of index PCI. TIMI flow grade 3 is achieved in 90.9% of patients without IPST vs. 44.7% in patients with IPST. Given its significant and unique role in outcome, there is currently increasing advocacy to routinely report IPST in PCI and to add it as a distinctive entity in the Academic Research Consortium (ARC) definition of stent thrombosis.[2]
Intraprocedural and follow-up data on patients who experience IPST reveal the most common significant complications. The occurrence of IPST remarkably increases the risk of occurrence of IPTE-related complications. The following table summarizes intra-procedural complications of IPST.[2]
| Intraprocedural Complications | Patients with IPST | Patients without IPST |
| Slow or no reflow | 75.5% | 3.2% |
| Distal Embolization | 49% | 1.9% |
| Side branch closure | 14.3% | 0.6% |
Similar to IPTE in general, IPST is an important independent predictor of mortality and morbidity one year post-PCI. One year follow-up data shows a 41.1% rate of death, MI, or TVR in patients who had experienced IPST vs. only 14.5% in patients with no IPST.[2] Other adverse events were also increased in patients with IPST after one year post-PCI, such as postprocedural stent thrombosis, TVR, and non-CABG major bleeding.[7][2]
References
- ↑ 1.0 1.1 1.2 1.3 Xu Y, Qu X, Fang W, Chen H (2013). "Prevalence, correlation and clinical outcome of intra-procedural stent thrombosis in patients undergoing primary percutaneous coronary intervention for acute coronary syndrome". J Interv Cardiol. 26 (3): 215–20. doi:10.1111/joic.12029. PMID 23551235.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Brener, SJ.; Cristea, E.; Kirtane, AJ.; McEntegart, MB.; Xu, K.; Mehran, R.; Stone, GW. (2013). "Intra-procedural stent thrombosis: a new risk factor for adverse outcomes in patients undergoing percutaneous coronary intervention for acute coronary syndromes". JACC Cardiovasc Interv. 6 (1): 36–43. doi:10.1016/j.jcin.2012.08.018. PMID 23266233. Unknown parameter
|month=ignored (help) - ↑ Babinska A, Markell MS, Salifu MO, Akoad M, Ehrlich YH, Kornecki E (1998). "Enhancement of human platelet aggregation and secretion induced by rapamycin". Nephrol Dial Transplant. 13 (12): 3153–9. PMID 9870481.
- ↑ McKeage K, Murdoch D, Goa KL (2003). "The sirolimus-eluting stent: a review of its use in the treatment of coronary artery disease". Am J Cardiovasc Drugs. 3 (3): 211–30. PMID 14727933.
- ↑ 5.0 5.1 Kereiakes DJ, Choo JK, Young JJ, Broderick TM (2004). "Thrombosis and drug-eluting stents: a critical appraisal". Rev Cardiovasc Med. 5 (1): 9–15. PMID 15029110.
- ↑ 6.0 6.1 6.2 6.3 Chieffo A, Bonizzoni E, Orlic D, Stankovic G, Rogacka R, Airoldi F; et al. (2004). "Intraprocedural stent thrombosis during implantation of sirolimus-eluting stents". Circulation. 109 (22): 2732–6. doi:10.1161/01.CIR.0000131890.83839.5B. PMID 15148281.
- ↑ 7.0 7.1 Xu, Y.; Qu, X.; Fang, W.; Chen, H. (2013). "Prevalence, correlation and clinical outcome of intra-procedural stent thrombosis in patients undergoing primary percutaneous coronary intervention for acute coronary syndrome". J Interv Cardiol. 26 (3): 215–20. doi:10.1111/joic.12029. PMID 23551235. Unknown parameter
|month=ignored (help) - ↑ 8.0 8.1 Biondi-Zoccai GG, Sangiorgi GM, Chieffo A, Vittori G, Falchetti E, Margheri M; et al. (2005). "Validation of predictors of intraprocedural stent thrombosis in the drug-eluting stent era". Am J Cardiol. 95 (12): 1466–8. doi:10.1016/j.amjcard.2005.01.099. PMID 15950573.
- ↑ Ge L, Airoldi F, Iakovou I, Cosgrave J, Michev I, Sangiorgi GM; et al. (2005). "Clinical and angiographic outcome after implantation of drug-eluting stents in bifurcation lesions with the crush stent technique: importance of final kissing balloon post-dilation". J Am Coll Cardiol. 46 (4): 613–20. doi:10.1016/j.jacc.2005.05.032. PMID 16098424.
- ↑ 10.0 10.1 10.2 10.3 10.4 Brener SJ, Cristea E, Kirtane AJ, McEntegart MB, Xu K, Mehran R; et al. (2013). "Intra-procedural stent thrombosis: a new risk factor for adverse outcomes in patients undergoing percutaneous coronary intervention for acute coronary syndromes". JACC Cardiovasc Interv. 6 (1): 36–43. doi:10.1016/j.jcin.2012.08.018. PMID 23266233.
- ↑ Hoye A, Iakovou I, Ge L, van Mieghem CA, Ong AT, Cosgrave J; et al. (2006). "Long-term outcomes after stenting of bifurcation lesions with the "crush" technique: predictors of an adverse outcome". J Am Coll Cardiol. 47 (10): 1949–58. doi:10.1016/j.jacc.2005.11.083. PMID 16697310.