Stent thrombosis: How to manage it Dr Philip MacCarthy BSc PhD FRCP Consultant Cardiologist King s College Hospital, London, UK.

Transcription

1 Stent thrombosis: How to manage it Dr Philip MacCarthy BSc PhD FRCP Consultant Cardiologist King s College Hospital, London, UK. ACI 2011 Weds 26th Jan

2 NO CONFLICT OF INTEREST TO DECLARE

3 A Step-wise practical guide Background facts: May occur a long time after PCI Occurs with BMS as well as DES Often associated with alterations in DAPT Has a poor outcome

4 The poor outcome of stent thrombosis Kimura et al RESTART Circulation Jul 6;122(1):52-61

5 Step 1: Get the diagnosis right Usually presents with ST segment elevation MI History/details of previous PCI often lacking Should be considered even if stenting is many years ago or BMS used

6 4yr Drug-eluting stent thrombosis Before June 2006 Nov 2010

7 Step 1: Get the diagnosis right High index of suspicion when DAPT interrupted Kimura et al RESTART Circulation Jul 6;122(1):52-61

8 Outcome just as bad with BMS n=55 n=43 Burzotta et al, Eur Heart J 2008;29:

9 Step 2: Adjunctive pharmacology Lack of evidence in this specific population Assume a moderate/high thrombus burden Oral: IV: Prasugrel most appropriate Reopro probably most appropriate (no data) - 'upstream' preferable Wt-adjusted UFH Bivalirudin reasonable alternative

10 Evidence for GPIIb/IIIa Wenewesar Eur Heart J 2005;26:1180

11 Step 3: A careful diagnostic angiogram

12 Step 3: A careful diagnostic angiogram Radial access makes sense Thrombus often propagates proximally Consider new disease adjacent to stent 'Stent boost' feature - useful for stent edges

13 Step 4: Wiring Often surprisingly difficult Easy to 'pick up a strut' - consider if a small balloon will not easily pass through the stent - re-wire if any doubt Soft-tipped wire 'on a loop' Can use support wire if proximal vessel very tortuous (esp. if thrombectomy/ivus planned)

14 Step 5: Thrombectomy Should always try to perform thrombectomy - if possible before other instrumentation Smaller catheter with stylet often easier (eg. Pronto LP). Bulky thrombectomy catheters get stuck on the stent Can use thrombectomy catheter to administer ic. adenosine if slow/no re-flow

15 Most try to use thrombectomy Kimura et al RESTART Circulation Jul 6;122(1):52-61

16 Step 6: Adjunctive imaging Mandatory (even in the middle of the night!) IVUS: Stent under-expansion True vessel size Areas of calcification Disease at in/out-flow of stent Post-interventional result OCT: Strut malapposition

17 IVUS - Thrombus

18 IVUS - intraluminal anatomy Distal intimal dissection Malapposition of proximal stent

19 OCT imaging Ozaki et al Eur Heart J (2010) 31 (12): Matsumoto et al Eur Heart J (2007) 28 (8):

20 Step 7: Re-intervention Depends on what has caused the stent thrombosis Stent strut malapposition IVUS-guided NC balloon to high pressure Cook et al Circulation 2007;115:2426

21 Step 7: Re-intervention Depends on what has caused the stent thrombosis Stent strut malapposition IVUS-guided NC balloon to high pressure No mechanical problem - eg Inappropriate DAPT cessation - POBA with semi-compliant balloon for thrombus (post-thrombectomy) In-flow/out-flow disease Re-stenting - caution with DES if problems with DAPT compliance

22 Step 7: Re-intervention Try to avoid putting more metalwork in if possible Burzotta et al, Eur Heart J 2008;29:

23 ESTROFA J Am Coll Cardiol 2008;51: Burzotta et al, Eur Heart J 2008;29:

24 Step 7: Re-intervention Slow flow predicts a poor outcome Burzotta et al, Eur Heart J 2008;29:

25 Slow flow predicts a poor outcome

26 Step 8: Post re-intervention management Depends on the cause - but consider: Platelet function testing (eg.verifynow) Prasugrel anyway 1 year for both DES and BMS stent thrombosis Patient education if compliance an issue (Cardiac rehab teams, patient DAPT card etc)

27 Conclusions Stent thrombosis carries a high mortality and needs to be recognised/diagnosed promptly Appropriate (upstream) pharmacology and thrombectomy are important IVUS/OCT vital for a good re-intervention Try to avoid re-stenting Careful thought about antiplatelet sensitivity/treatment post-stent thrombosis

28 Acknowledgements Jon Byrne for IVUS images

29

30 The poor outcome of stent thrombosis Burzotta et al, Eur Heart J 2008;29:

31 Representative optical coherence tomography-derived cross-sectional image demonstrating thrombus associated with an incompletely apposed stent strut (left panel) as well as thrombus associated without incompletely apposed stent strut (right panel). Ozaki Y et al. Eur Heart J 2010;31: Published on behalf of the European Society of Cardiology. All rights reserved. The Author For permissions please journals.permissions@oxfordjournals.org

32 Presentation of stent thrombosis ESTROFA J Am Coll Cardiol 2008;51:986