Mechanisms of Very Late Drug-Eluting Stent Thrombosis Assessed by Optical Coherence Tomography

Masanori Taniwaki; Maria D Radu; Serge Zaugg; Nicolas Amabile; Hector M Garcia-Garcia; Kyohei Yamaji; Erik Jørgensen; Henning Kelbæk; Thomas Pilgrim; Christophe Caussin; Thomas Zanchin; Aurelie Veugeois; Ulrik Abildgaard; Peter Jüni; Stephane Cook; Konstantinos C Koskinas; Stephan Windecker; Lorenz Räber

doi:10.1161/CIRCULATIONAHA.115.019071

Mechanisms of Very Late Drug-Eluting Stent Thrombosis Assessed by Optical Coherence Tomography

Circulation. 2016 Feb 16;133(7):650-60. doi: 10.1161/CIRCULATIONAHA.115.019071. Epub 2016 Jan 13.

Authors

Masanori Taniwaki¹, Maria D Radu¹, Serge Zaugg¹, Nicolas Amabile¹, Hector M Garcia-Garcia¹, Kyohei Yamaji¹, Erik Jørgensen¹, Henning Kelbæk¹, Thomas Pilgrim¹, Christophe Caussin¹, Thomas Zanchin¹, Aurelie Veugeois¹, Ulrik Abildgaard¹, Peter Jüni¹, Stephane Cook¹, Konstantinos C Koskinas¹, Stephan Windecker¹, Lorenz Räber²

Affiliations

¹ From Department of Cardiology, Bern University Hospital, Switzerland (M.T., K.Y., T.P., T.Z., K.C.K., S.W., L.R.); Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen, Denmark (M.D.R., E..J.); Clinical Trials Unit, Bern University, Bern, Switzerland (S.Z.) Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital, and Department of Medicine, University of Toronto, Canada (P.J.); Department of Cardiology, Institut Mutualiste Montsouris, Paris, France (N.A., C.C., A.V.); Interventional Cardilogy, Washington Hospital Center, Washington, DC (H.M.G.-G.); Department of Cardiology, Roskilde Hospital, Denmark (H.K.); Department of Cardiology, Copenhagen University Hospital Gentofte, Gentofte, Denmark (U.A.); and Department of Cardiology, Fribourg University and Hospital, Switzerland (S.C.).
² From Department of Cardiology, Bern University Hospital, Switzerland (M.T., K.Y., T.P., T.Z., K.C.K., S.W., L.R.); Department of Cardiology, The Heart Center, Rigshospitalet, Copenhagen, Denmark (M.D.R., E..J.); Clinical Trials Unit, Bern University, Bern, Switzerland (S.Z.) Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital, and Department of Medicine, University of Toronto, Canada (P.J.); Department of Cardiology, Institut Mutualiste Montsouris, Paris, France (N.A., C.C., A.V.); Interventional Cardilogy, Washington Hospital Center, Washington, DC (H.M.G.-G.); Department of Cardiology, Roskilde Hospital, Denmark (H.K.); Department of Cardiology, Copenhagen University Hospital Gentofte, Gentofte, Denmark (U.A.); and Department of Cardiology, Fribourg University and Hospital, Switzerland (S.C.). lorenz.raeber@insel.ch.

PMID: 26762519
DOI: 10.1161/CIRCULATIONAHA.115.019071

Abstract

Background: The pathomechanisms underlying very late stent thrombosis (VLST) after implantation of drug-eluting stents (DES) are incompletely understood. Using optical coherence tomography, we investigated potential causes of this adverse event.

Methods and results: Between August 2010 and December 2014, 64 patients were investigated at the time point of VLST as part of an international optical coherence tomography registry. Optical coherence tomography pullbacks were performed after restoration of flow and analyzed at 0.4 mm. A total of 38 early- and 20 newer-generation drug-eluting stents were suitable for analysis. VLST occurred at a median of 4.7 years (interquartile range, 3.1-7.5 years). An underlying putative cause by optical coherence tomography was identified in 98% of cases. The most frequent findings were strut malapposition (34.5%), neoatherosclerosis (27.6%), uncovered struts (12.1%), and stent underexpansion (6.9%). Uncovered and malapposed struts were more frequent in thrombosed compared with nonthrombosed regions (ratio of percentages, 8.26; 95% confidence interval, 6.82-10.04; P<0.001 and 13.03; 95% confidence interval, 10.13-16.93; P<0.001, respectively). The maximal length of malapposed or uncovered struts (3.40 mm; 95% confidence interval, 2.55-4.25; versus 1.29 mm; 95% confidence interval, 0.81-1.77; P<0.001), but not the maximal or average axial malapposition distance, was greater in thrombosed compared with nonthrombosed segments. The associations of both uncovered and malapposed struts with thrombus were consistent among early- and newer-generation drug-eluting stents.

Conclusions: The leading associated findings in VLST patients in descending order were malapposition, neoatherosclerosis, uncovered struts, and stent underexpansion without differences between patients treated with early- and new-generation drug-eluting stents. The longitudinal extension of malapposed and uncovered stent was the most important correlate of thrombus formation in VLST.

Keywords: drug-eluting stents; stents; thrombosis; tomography, optical coherence.

Publication types

Observational Study
Research Support, Non-U.S. Gov't

MeSH terms

Aged
Coronary Vessels / pathology*
Coronary Vessels / surgery
Cross-Sectional Studies
Drug-Eluting Stents / adverse effects*
Drug-Eluting Stents / standards
Drug-Eluting Stents / trends*
Female
Humans
Male
Middle Aged
Prosthesis Failure
Thrombosis / diagnosis*
Thrombosis / etiology*
Time Factors
Tomography, Optical Coherence / methods*