CLINICAL COMMUNICATION TO THE EDITOR
Left Main Coronary Artery Stent Thrombosis: A Challenging Case To the Editor: Percutaneous coronary intervention with placement of a coronary stent to an unprotected left main coronary artery Funding: None. Conflict of Interest: None. Authorship: Both authors had access to the data and a role in preparing the manuscript. Requests for reprints should be addressed to Konstantinos Dean Boudoulas, MD, Department of Medicine/Cardiovascular Medicine, The Ohio State University, 473 W. 12th Avenue, Suite 200, Columbus, OH 43210. E-mail address: [email protected]
has become a viable alternative to coronary artery bypass surgery. Although stent thrombosis is rare, it is a devastating complication of percutaneous coronary intervention with significant morbidity and mortality, especially if it involves an unprotected left main coronary artery. We describe a case of left main stent thrombosis managed initially by percutaneous coronary intervention followed by coronary artery bypass surgery. A 50-year-old male nonsmoker with a medical history significant for diabetes mellitus type II, hypertension, and coronary artery disease presented with acute chest pain and cardiogenic shock. Two months prior, he had a similar presentation due to an anterolateral ST-elevation myocardial infarction. Coronary arteriography demonstrated plaque
Figure (A) Coronary arteriogram demonstrating left main (LM) coronary artery stent thrombosis (white arrow) with complete occlusion of the LM. (B) Intravascular ultrasound was performed after manual aspiration thrombectomy showing LM stent strut (white arrows) malapposition to vessel wall (asterisk). (C) The stent in the LM was appropriately expanded using coronary balloon inflation; note coronary guidewires in the left anterior descending (LAD) and left circumflex (LCx) arteries. (D) Coronary arteriogram post procedure performed in the left anterior oblique and caudal projection demonstrating a patent LM stent (white arrow) with restoration of flow in the LAD and LCx arteries.
0002-9343/$ -see front matter Ó 2014 Elsevier Inc. All rights reserved.
e10 rupture within the left main coronary artery, and a bare metal stent was placed. At that time, he was discharged on aspirin 325 mg daily and clopidogrel 75 mg daily; however, the patient discontinued clopidogrel 1 month later and remained on aspirin. During the current presentation, the electrocardiogram showed ST-segment elevation in the anterolateral precordial leads consistent with acute myocardial infarction. The patient emergently underwent coronary arteriography revealing left main coronary artery stent thrombosis resulting in complete occlusion of the artery (Figure, A). Manual aspiration thrombectomy was performed restoring coronary blood flow. Intravascular ultrasound revealed stent malapposition to the wall of the left main coronary artery (Figure, B); balloon angioplasty was performed apposing the preexisting stent against the arterial wall (Figure, C). Postprocedure coronary arteriogram demonstrated a patent left main stent (Figure, D). The patient had full recovery after percutaneous coronary intervention; however, it was felt that he would benefit from coronary artery bypass surgery, which was performed before discharge. Stent thrombosis is a devastating complication of percutaneous coronary intervention. The 1-year incidence is approximately 1% regardless of stent type; however, the incidence of left main stent thrombosis, although rare, has not been precisely defined. Mortality from left main stent thrombosis also remains to be defined, but is likely extremely high without prompt intervention. Numerous factors may contribute to stent thrombosis, and in this case, stent thrombosis most likely resulted from stent malapposition and cessation of dual antiplatelet therapy.1,2 It is suggested that intravascular ultrasound be performed on all patients with left main stent placement to decrease stent malapposition, and therefore, stent thrombosis.3 Currently, it is recommended that dual antiplatelet therapy be continued for at least 1 month after bare metal stent placement and 1 year after drug eluting stent
The American Journal of Medicine, Vol 127, No 5, May 2014 placement. Aspirin should be continued indefinitely regardless of stent type.4 The appropriate duration of dual antiplatelet therapy after a stent placement in the left main coronary artery, regardless of stent type, remains to be defined and should be discussed with the patient’s cardiologist. It is not clear how patients with left main stent thrombosis should be managed if they survive the acute event. Given the catastrophic nature, coronary artery bypass surgery should be considered, especially in a noncompliant patient; however, patency of a bypass, particularly vein grafts, may be compromised in a patient with a patent left main stent. Development of a registry of left main stent thrombosis to define frequency and optimal treatment after surviving the acute event is warranted. Kyle Pfahl, MD Konstantinos Dean Boudoulas, MD Division of Cardiovascular Medicine The Ohio State University Medical Center Columbus
http://dx.doi.org/10.1016/j.amjmed.2014.01.026
References 1. Sarno G, Lagerqvist B, Fröbert O, et al. Lower risk of stent thrombosis and restenosis with unrestricted use of ‘new-generation’ drug-eluting stents: a report from the nationwide Swedish Coronary Angiography and Angioplasty Registry (SCAAR). Eur Heart J. 2012;33:606-613. 2. Mylotte D, Meftout B, Moynagh A, et al. Unprotected left main stenting in the real world: five-year outcomes of the French left main taxus registry. EuroIntervention. 2012;8:970-981. 3. McDaniel C, Douglas J. Stent area by intravascular ultrasound and outcomes in left main intervention with drug-eluting stents. Circ Cardiovasc Interv. 2011;4:542-544. 4. Dangas GD, Claessen BE, Mehran R, et al. Stent thrombosis after primary angioplasty for STEMI in relation to non-adherence to dual antiplatelet therapy over time: results of the HORIZONS-AMI trial. EuroIntervention. 2013;8:1033-1039.
Left Main Coronary Artery Stent Thrombosis: A Challenging Case To the Editor: Percutaneous coronary intervention with placement of a coronary stent to an unprotected left main coronary artery Funding: None. Conflict of Interest: None. Authorship: Both authors had access to the data and a role in preparing the manuscript. Requests for reprints should be addressed to Konstantinos Dean Boudoulas, MD, Department of Medicine/Cardiovascular Medicine, The Ohio State University, 473 W. 12th Avenue, Suite 200, Columbus, OH 43210. E-mail address: [email protected]
has become a viable alternative to coronary artery bypass surgery. Although stent thrombosis is rare, it is a devastating complication of percutaneous coronary intervention with significant morbidity and mortality, especially if it involves an unprotected left main coronary artery. We describe a case of left main stent thrombosis managed initially by percutaneous coronary intervention followed by coronary artery bypass surgery. A 50-year-old male nonsmoker with a medical history significant for diabetes mellitus type II, hypertension, and coronary artery disease presented with acute chest pain and cardiogenic shock. Two months prior, he had a similar presentation due to an anterolateral ST-elevation myocardial infarction. Coronary arteriography demonstrated plaque
Figure (A) Coronary arteriogram demonstrating left main (LM) coronary artery stent thrombosis (white arrow) with complete occlusion of the LM. (B) Intravascular ultrasound was performed after manual aspiration thrombectomy showing LM stent strut (white arrows) malapposition to vessel wall (asterisk). (C) The stent in the LM was appropriately expanded using coronary balloon inflation; note coronary guidewires in the left anterior descending (LAD) and left circumflex (LCx) arteries. (D) Coronary arteriogram post procedure performed in the left anterior oblique and caudal projection demonstrating a patent LM stent (white arrow) with restoration of flow in the LAD and LCx arteries.
0002-9343/$ -see front matter Ó 2014 Elsevier Inc. All rights reserved.
e10 rupture within the left main coronary artery, and a bare metal stent was placed. At that time, he was discharged on aspirin 325 mg daily and clopidogrel 75 mg daily; however, the patient discontinued clopidogrel 1 month later and remained on aspirin. During the current presentation, the electrocardiogram showed ST-segment elevation in the anterolateral precordial leads consistent with acute myocardial infarction. The patient emergently underwent coronary arteriography revealing left main coronary artery stent thrombosis resulting in complete occlusion of the artery (Figure, A). Manual aspiration thrombectomy was performed restoring coronary blood flow. Intravascular ultrasound revealed stent malapposition to the wall of the left main coronary artery (Figure, B); balloon angioplasty was performed apposing the preexisting stent against the arterial wall (Figure, C). Postprocedure coronary arteriogram demonstrated a patent left main stent (Figure, D). The patient had full recovery after percutaneous coronary intervention; however, it was felt that he would benefit from coronary artery bypass surgery, which was performed before discharge. Stent thrombosis is a devastating complication of percutaneous coronary intervention. The 1-year incidence is approximately 1% regardless of stent type; however, the incidence of left main stent thrombosis, although rare, has not been precisely defined. Mortality from left main stent thrombosis also remains to be defined, but is likely extremely high without prompt intervention. Numerous factors may contribute to stent thrombosis, and in this case, stent thrombosis most likely resulted from stent malapposition and cessation of dual antiplatelet therapy.1,2 It is suggested that intravascular ultrasound be performed on all patients with left main stent placement to decrease stent malapposition, and therefore, stent thrombosis.3 Currently, it is recommended that dual antiplatelet therapy be continued for at least 1 month after bare metal stent placement and 1 year after drug eluting stent
The American Journal of Medicine, Vol 127, No 5, May 2014 placement. Aspirin should be continued indefinitely regardless of stent type.4 The appropriate duration of dual antiplatelet therapy after a stent placement in the left main coronary artery, regardless of stent type, remains to be defined and should be discussed with the patient’s cardiologist. It is not clear how patients with left main stent thrombosis should be managed if they survive the acute event. Given the catastrophic nature, coronary artery bypass surgery should be considered, especially in a noncompliant patient; however, patency of a bypass, particularly vein grafts, may be compromised in a patient with a patent left main stent. Development of a registry of left main stent thrombosis to define frequency and optimal treatment after surviving the acute event is warranted. Kyle Pfahl, MD Konstantinos Dean Boudoulas, MD Division of Cardiovascular Medicine The Ohio State University Medical Center Columbus
http://dx.doi.org/10.1016/j.amjmed.2014.01.026
References 1. Sarno G, Lagerqvist B, Fröbert O, et al. Lower risk of stent thrombosis and restenosis with unrestricted use of ‘new-generation’ drug-eluting stents: a report from the nationwide Swedish Coronary Angiography and Angioplasty Registry (SCAAR). Eur Heart J. 2012;33:606-613. 2. Mylotte D, Meftout B, Moynagh A, et al. Unprotected left main stenting in the real world: five-year outcomes of the French left main taxus registry. EuroIntervention. 2012;8:970-981. 3. McDaniel C, Douglas J. Stent area by intravascular ultrasound and outcomes in left main intervention with drug-eluting stents. Circ Cardiovasc Interv. 2011;4:542-544. 4. Dangas GD, Claessen BE, Mehran R, et al. Stent thrombosis after primary angioplasty for STEMI in relation to non-adherence to dual antiplatelet therapy over time: results of the HORIZONS-AMI trial. EuroIntervention. 2013;8:1033-1039.
