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 May occur a long time after PCI Occurs with BMS as well as DES Occurs with BMS as well as DES Often associated with alterations in DAPT Often associated with alterations in DAPT Has a poor outcome Has a poor outcome

4. The poor outcome of stent thrombosis Kimura et al RESTART Circulation. 2010 Jul 6;122(1):52-61

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

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

7. Step 1: Get the diagnosis right High index of suspicion when DAPT interrupted High index of suspicion when DAPT interrupted Kimura et al RESTART Circulation. 2010 Jul 6;122(1):52-61

8. Outcome just as bad with BMS Burzotta et al, Eur Heart J 2008;29:3011-21 n=55 n=43

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

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

11. Step 3: A careful diagnostic angiogram

12. Radial access makes sense Radial access makes sense Thrombus often propagates proximally Thrombus often propagates proximally Consider new disease adjacent to stent Consider new disease adjacent to stent 'Stent boost' feature - useful for stent edges 'Stent boost' feature - useful for stent edges

13. Step 4: Wiring Often surprisingly difficult 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 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' Soft-tipped wire 'on a loop' Can use support wire if proximal vessel very tortuous (esp. if thrombectomy/IVUS planned) 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 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 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 Can use thrombectomy catheter to administer ic. adenosine if slow/no re-flow

15. Most try to use thrombectomy Kimura et al RESTART Circulation. 2010 Jul 6;122(1):52-61

16. Step 6: Adjunctive imaging Mandatory (even in the middle of the night!) Mandatory (even in the middle of the night!) IVUS: IVUS: Stent under-expansion Stent under-expansion True vessel size True vessel size Areas of calcification Areas of calcification Disease at in/out-flow of stent Disease at in/out-flow of stent Post-interventional result Post-interventional result OCT: OCT: Strut malapposition 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): 1470-1476.Matsumoto et al Eur Heart J (2007) 28 (8): 961-967.

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

22. Try to avoid putting more metalwork in if possible Step 7: Re-intervention Burzotta et al, Eur Heart J 2008;29:3011-21

23. ESTROFA J Am Coll Cardiol 2008;51:986-90

24. Slow flow predicts a poor outcome Step 7: Re-intervention Burzotta et al, Eur Heart J 2008;29:3011-21

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) Platelet function testing (eg.VerifyNow) Prasugrel anyway Prasugrel anyway 1 year for both DES and BMS stent thrombosis 1 year for both DES and BMS stent thrombosis Patient education if compliance an issue (Cardiac rehab teams, patient DAPT card etc) 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 Stent thrombosis carries a high mortality and needs to be recognised/diagnosed promptly Appropriate (upstream) pharmacology and thrombectomy are important Appropriate (upstream) pharmacology and thrombectomy are important IVUS/OCT vital for a good re-intervention IVUS/OCT vital for a good re-intervention Try to avoid re-stenting Try to avoid re-stenting Careful thought about antiplatelet sensitivity/treatment post-stent thrombosis Careful thought about antiplatelet sensitivity/treatment post-stent thrombosis

28. Acknowledgements Jon Byrne for IVUS images Jon Byrne for IVUS images

30. Burzotta et al, Eur Heart J 2008;29:3011-21 The poor outcome of stent thrombosis

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;31:1470-1476 Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2010. For permissions please email: journals.permissions@oxfordjournals.org

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