Late stent thrombosis Ashish shah, Tim Kinnaird, W J Penny

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Presentation transcript:

Late stent thrombosis Ashish shah, Tim Kinnaird, W J Penny University Hospital of Wales, Cardiff, UK

History 75 years old – retired physiotherapist Hypertension, hypercholesterolemia Refractory angina PCI to LAD and LCx – 2008 PCI to prox-mid RCA – March – 09 3.5 x 13 mm Cypher (prox) and 3.0 x 33 mm Cypher stent (distally) with overlap Post dilated with 3.5 mm NCB

PCI - 2009 2 2 1 Diagnostic angiography – LCx Diagnostic angiography – LAD

PCI to mid RCA 2 1 Diagnostic angiography – RCA 3.0 x 33 mm Cypher stent in mid RCA

PCI to mid RCA 1 2 Balloon post dilatation of mid RCA – stented segment 3.5 x 13 mm Cypher in mid RCA; post dilated with 3.5 mm NCB

Final cine – March 09

Readmission Completely asymptomatic till Dec 12 Cutting log, walks 4-5 miles every day While decorating Christmas tree 1st episode of chest pain and nauseated ECG – Inferior STEMI Primary PCI call activated

Diagnostic angiography – Dec 12 Diagnostic angiography – LCx Diagnostic angiography - LAD

Occluded mid RCA 2 1 Diagnostic angiography – RCA Post thrombus aspiration x 6

OCT – after thrombus aspiration 1 2 Mean luminal area (MLA) – distal to stent – 7.8 mm2 MLA – distal part of stented segment – 5.5 mm2 ( post dilated with 3.5 mm NCB. Vessel measurement – 2.4 x 2.8 mm2)

Cine after thrombus aspiration Cine post PCI - 2009

Post dilation with 3.75 mm NCB

Mean luminal area (MLA) – distal to stent – 7.7 mm2 OCT – post ballooning 1 2 2 Mean luminal area (MLA) – distal to stent – 7.7 mm2 MLA – distal part of stented segment – 10.1mm2 ( post dilated with 3.5 mm NCB. Vessel measurement – 3.5 x 3.7 mm2)

OCT of stented segment (Post POBA) 1 1

Final cine

Summary Late stent thrombosis Under expanded stent / long stent Can be fatal Important to understand / define mechanism Check it post procedure (POBA / Stenting) IVUS / OCT guided PCI

Conclusion In each case of stent thrombosis – it is vital to know the underlying mechanism Under-sized stent / poor expansion - apposition / long stent Management strategy based upon the underlying problem OCT – helps understanding mechanism very well 1 2