1. The Pathology of Cardiac Interventions Dr Stephen Preston Royal Bournemouth Hospital Dr Patrick J Gallagher University of Southampton

2. Problems for the Pathologist As the number of interventions increase all pathologists will perform autopsies on patients with stents Finding and dissecting stents can be difficult Two questions: is the stent patent? If not is it thrombus or fibrous tissue? What is the appearance of the myocardial infarct?

4. No endothelium

10. Late DES failure 23 DES cases, died >30 days post procedure 14 (61%) had stent thrombosis (one died of stroke) 7 (30%) had patent stent(s) 4 cardiac deaths 2 (9%) had stent restenosis (both died of AMI/SCD) 3 non-cardiac deaths Joner M et al, J Am Coll Cardiol 2006;48:193-202

11. Pathological factors in stent thrombosis Delayed endothelial coverage –Necessary for thrombosis, rare in bare metal stents –Maximum mean DES coverage 60-70% –More common with ruptured plaques Pro-thrombotic material –Thrombus –Penetration of necrotic plaque core –Hypersensitivity/inflammation? Abnormal flow –Malapposition –Restenosis

12. Limitations to the coroner’s autopsy Coroner’s duty: –Who died, when, where and how Purpose of autopsy in non-suspicious cases: –Provide a medical cause of death Finance –112 coroners, £71million total budget 50% on autopsy, mortuary, toxicology etc Human tissue act Training of pathologists

13. Solutions Improved training for registrars in histopathology UK Cardiac Pathology Network Chief coroner? Medical examiners?

14. References Carlsson J et al. Is late stent thrombosis a real clinical issue? A single-center experience and review of the literature. Clin Res Cardiol 2007;96:86-93. Finn AV et al. Vascular responses to drug eluting stents: importance of delayed healing. Arterioscler Thromb Vasc Biol 2007;27:1500-10. Finn AV et al. Does underlying plaque morphology play a role in vessel healing after drug-eluting stent implantation? J Am Coll Cardiol Img 2008;1:485-8. Joner M et al. Pathology of drug eluting stents in humans. Delayed healing and late thrombotic risk. J Am Coll Cardiol 2006;48:193-202. Luescher TF et al. Drug-eluting stent and coronary thrombosis: biological mechanisms and clinical implications. Circulation 2007;115:1051-8.