Case Report
JLA
http://dx.doi.org/10.12997/jla.2014.3.1.43 pISSN 2287-2892 • eISSN 2288-2561
Acute Stent Thrombosis after Coronary Stenting in Patients with Acute Coronary Syndrome Hyo-Sun Shin1,3, Sang-Hyun Kim2,3, Hack-Lyoung Kim2,3, Jae-Bin Seo2,3, Woo-Young Chung2,3, Joo-Hee Zo2,3, Myung-A Kim2,3 1
Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Division of Cardiology, Department of Internal Medicine, Seoul Boramae Medical Center, Seoul, 3 Seoul National University College of Medicine, Seoul, Korea 2
Acute stent thrombosis after percutaneous coronary intervention (PCI) is still problematic because of the subsequent development of myocardial infarction and poor prognosis. The incidence of acute stent thrombosis, occurring within 0-24hours after PCI, is relatively low, but underlying causes and treatment strategy are not well defined. Multi-vessel disease, ST-elevated myocardial infarction (STEMI), and large thrombotic burden are known risk factors of acute stent thrombosis. Thrombus aspiration, balloon angioplasty and glycoprotein IIb/IIIa receptor blocker could be therapeutic options. Recently we experienced two cases of acute stent thrombosis which developed during PCI with the aggravation of chest pain, and acute stent thrombosis were diagnosed immediately and successfully treated. Here we report two cases of acute stent thrombosis during PCI for one patient with STEMI and the other with acute coronary syndrome, which were successfully treated with thrombus aspiration and intravenous infusion of glycoprotein IIb/IIIa receptor blocker. Key Words: Coronary thrombosis, Acute coronary syndrome, Abciximab
INTRODUCTION
Physician’s concept or suspicion of acute stent thrombosis can be enough for the diagnosis and improve the
After the advent of percutaneous coronary inter-
prognosis of those patients. Here we report two cases
vention (PCI), mortality of acute coronary syndrome
of acute stent thrombosis during PCI for one patient with
continues to decline, but stent thrombosis (ST) after PCI
ST-elevated myocardial infarction (STEMI) and the other
remains a residual problem of the procedure. ST occurs
with acute coronary syndrome, which were successfully
1-7
about 1-2% of total PCI cases
and acute stent throm-
bosis, occurring within 0-24hours after PCI, accounts for 1,8
6-25% of all ST cases.
injection of glycoprotein IIb/IIIa inhibitor.
Although the incidence of ST is
relatively low, prognosis of ST is dismal; with a 5,7
case-fatality rate of 15-45%.
CASE 1
Nonetheless underlying
causes and treatment strategy of ST are not-well defined. Received: March 14, 2014 Revised: May 29, 2014 Accepted: June 11, 2014
treated with thrombus aspiration and intravenous
A 66-year-old man visited the Emergency Department
Corresponding Author: Sang-Hyun Kim, Division of Cardiology, Department of Internal Medicine, Seoul Boramae Medical Center, Seoul National University College of Medicine, 20, Borimae-ro, 5-gil, Dongak-gu, Seoul 156-707, Korea Tel: +82-2-870-3864, Fax: +82-2-870-3866, E-mail:
[email protected]
This is an Open Access article distributed under the terms of the creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Fig. 1. Initial electrocardiogram showed ST-segment elevation in leads I, avL, V1, V2, V3, V4 with reciprocal changes of ST-segment in leads II, III, and aVF.
with complaint of chest pain of squeezing nature which developed 30 minutes before. On admission, his blood
Left
pressure was 113/74 mmHg, and his heart rate was 94 beats per minute, and respiration rate was 30 /min. The electrocardiogram (ECG) showed ST-segment elevation in leads I, aVL, V1, V2, V3, V4 with reciprocal changes of ST-segment in leads II, III, and aVF (Fig. 1). The chest X-ray showed severe pulmonary edema (Fig. 2). Medical treatment was started immediately including aspirin 300 mg, clopidogrel 600 mg, intravenous nitrate infusion and bolus injection of unfractionated heparin 6,500 units. Unfractionated heparin was administered before PCI and repeatedly at every hour during PCI with monitoring activated clotting time for the maintenance over 300 seconds. He received emergent coronary angiography
Fig. 2. Initial chest X-ray showed bilateral pulmonary edema.
(CAG), and it showed total occlusion of the proximal left anterior descending coronary artery (LAD) with thrombus
limus eluting stent (3.0×18 mm Xience V stent, Abbott)
(Fig. 3-A) and segmental stenosis in left circumflex coro-
was inserted in proximal LAD at first (Fig. 3-B). Two
nary artery (LCX). There were stenotic lesions in middle
Everolimus eluting stents were inserted in proximal and
and distal right coronary artery (RCA). He showed severe
distal LCX. After PCI, patient suddenly complained of chest
pulmonary edema on chest x-ray and multiple stenotic
pain again. We checked the left coronary artery angiogram
lesions of coronary arteries, so we decided PCI on LAD
again and found newly developed intraluminal filling
and LCX. He underwent balloon angioplasty and evero-
defect due to stent thrombosis of the proximal LAD, which
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Hyo-Sun Shin, et al.: Acute Stent Thrombosis after Coronary Stenting
A
B
C
D
Fig. 3. (A) Left anterior oblique (LAO) projection with caudal angulation of selective left coronary angiogram showed the total occlusion with thrombus in the proximal part of left anterior descending artery (arrows), (B) LAO projection with cranial angulation of selective left CAG. Everolimus eluting stent (3.0×18 mm Xience V stent, Abbott, USA) was successfully placed in the LAD (arrows), (C) Right anterior oblique projection with cranial angulation of selective left CAG after RCA treatment showed intraluminal filling defect of the targeted lesion of LAD (arrows), (D) After thrombus aspiration and infusion of glycoprotein IIb/IIIa receptor blocker, CAG showed recovery of coronary flow.
was treated 45 minutes before (Fig. 3-C). After intravenous
C or S, anti-phospholipid antibody and no evidence of
administration of a glycoprotein IIb/IIIa receptor blocker
malignancy. He was discharged with triple anti-platelet
(Abciximab), thrombus aspiration and balloon angioplasty
therapy of aspirin 100 mg, clopidogrel 75 mg, and
were done. A final angiogram revealed improved flow
cilostazol 200 mg daily. This patient was followed-up via
through all coronary arteries (Fig. 3-D). 4 days after, a
outpatient clinic uneventfully, and repeat CAG performed
second look CAG showed patent flow through all stented
after 12 months showed patent coronary flow.
vessels. There were no predisposing factors including abnormal findings of coagulation system such as protein
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A
B
C
D
Fig. 4. (A) Right anterior oblique (RAO) projection with caudal angulation of selective left coronary angiogram showed the long segmental concentric stenosis in proximal to middle LAD and total occlusion in proximal LCX (arrows), (B) LAO projection with cranial angulation of selective left CAG. Two Everolimus eluting stents (2.5×28 mm and 3.0×23 mm Xience V stent, Abbott) were inserted in proximal and middle LAD, (C) LAO projection with cranial angulation of selective left CAG after LCX treatment showed intraluminal filling defect of the distal LAD (arrows), (D) After thrombus aspiration, infusion of glycoprotein IIb/IIIa receptor blocker and balloon angioplasty, CAG showed recovery of coronary flow.
CASE 2
left ventricle. Under assessment of acute coronary syndrome, the patient was treated aspirin 300 mg, clopidogrel
A 83 year-old woman was referred to our hospital with
600 mg and intravenous nitroglycerin infusion. Also,
complaints of dyspnea on exertion (New York Heart
unfractionated heparin was administered before PCI and
Association functional class III) from 1 month ago and
at every hour during PCI with monitoring activated clotting
hyponatremia with diuretic medication. Echocardiogra-
time for the maintenance over 300 seconds. She
phic examination showed hypokinesia of the anterior,
underwent CAG which showed critical stenosis in the LAD
inferolateral and inferior walls at base to mid-portion of
and LCX (Fig. 4-A). Balloon angioplasty was done and
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Hyo-Sun Shin, et al.: Acute Stent Thrombosis after Coronary Stenting two Everolimus eluting stents (2.5×28 mm and 3.0×23
onset or aggravation of chest pain or sudden abnormal
mm Xience V stent, Abbott) were inserted in the proximal
findings of vital signs. Immediate reexamination of
and middle LAD at first (Fig. 4-B), followed by two more
coronary flow should be recommended even during or
Everolimus eluting stents insertion in the proximal LCX.
immediate after previous coronary angiography and PCI
After successful treatment with LCX artery, she com-
bearing in mind the possibility of acute stent thrombosis.
plained of chest discomfort. CAG and intravenous
The most important thing for the diagnosis and treatment
ultrasonography (IVUS) revealed acute stent thrombosis
is clinical suspicion of acute stent thrombosis, which can
in the mid-portion of LAD artery (Fig. 4-C). Thrombus
be enough for the diagnosis and improve the prognosis
aspiration and infusion of glycoprotein IIb/IIIa receptor
of those patients. And multi-vessel PCI should be avoided
blocker were done, and post-treatment CAG showed
if there was no derangement of symptom, sign of poor
patent coronary flow (Fig. 4-D). After PCI, pulmonary
left ventricular function or pulmonary edema or the
edema disappeared and she showed the improvement
evidence of cardiogenic shock.
of functional status. There were no predisposing factors
Currently the diagnostic and treatment strategies are
including abnormal findings of coagulation system such
not well defined. Emergent repeat PCI (thrombus aspi-
as protein C or S, anti-phospholipid antibody and no
ration, balloon dilatation) is commonly employed, and
evidence of malignancy. She was discharged with triple
glycoprotein IIb/IIIa inhibitor is also used as ‘rescue’ therapy.
anti-platelet therapy using aspirin 100 mg, clopidogrel
Glycoprotein IIb/IIIa inhibitor inhibited platelet aggre-
75 mg, and cilostazol 200 mg daily. The patient was
gation and thrombus formation, and furthermore,
followed up via outpatient clinic without symptoms,
induced lysis of fresh thrombus. In addition, treatment
repeat CAG after 9 months showed patent coronary flow.
such as thrombus aspiration, intracoronary tirofiban injection has shown a favorable effect. The observational
DISCUSSION
study conducted by Akhtar MM, et al showed that the combined use of thrombectomy with glycoprotein IIb/IIIa
Drug-eluting stents have reduced restenosis rates and the necessity for target-vessel revascularization. However,
inhibitor improved outcome in patients with acute stent thrombosis.9
ST is still problematic. ST is a rare but catastrophic complication which frequently leads to death or myo-
CONCLUSION
cardial infarction. Recently, multiple risk factors associated with ST were
Acute ST during PCI was associated with multi-vessel
reported. Especially, patients with STEMI, multi-vessel
disease, STEMI, and large thrombotic burden. Therefore,
coronary artery disease, Killip class≥2 on admission, low
acute stent thrombosis can be successfully treated with
left ventricular ejection fraction (EF), small stent diameter,
thrombus aspiration, potent platelet aggregation inhibitor
long segmental stenosis and younger age are known to
and balloon angioplasty.
1,6
increase the risk of early ST.
These two cases were
examples of myocardial infarction with multi-vessel
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