Korean Circ J.  2011 Dec;41(12):754-758. 10.4070/kcj.2011.41.12.754.

Very Late Stent Thrombosis due to Neointimal Rupture After Paclitaxel-Eluting Stent Implantation

• Kee WJ
• Jeong MH
• Jang SY
• Lee MG
• Park KH
• Sim DS
• Hong YJ
• Kim JH
• Ahn Y
• Kang JC

• KMID: 1776253
• DOI: http://doi.org/10.4070/kcj.2011.41.12.754

Abstract

We report our experience of very late stent thrombosis (VLST) in a young male patient who underwent implantation of two paclitaxel-eluting stents (PES) six years ago. The patient was compliant with standard dual antiplatelet therapy, but he presented with acute myocardial infarction which was associated with VLST. Intravascular ultrasound showed neointimal rupture with thrombus within the PES implanted in the right coronary artery. The lesion was successfully treated with balloon angioplasty without complications, however he was found to be hyporesponsive to clopidogrel when tested for adenosine diphosphate-induced platelet aggregation. The patient was discharged after uneventful recovery with triple anti-platelet therapy using aspirin, clopidogrel and cilostazol. To the best of our knowledge, a time interval of 2,223 days is the longest reported time interval between PES deployment and VLST occurrence. VLST may indeed occur in clinically stable patients, as multiple factors can influence the pathological mechanisms of VLST.

Keyword

Coronary thrombosis; Paclitaxel; Ultrasonics; Clopidogrel

MeSH Terms

Adenosine
Angioplasty, Balloon
Aspirin
Coronary Thrombosis
Coronary Vessels
Humans
Male
Myocardial Infarction
Paclitaxel
Platelet Aggregation
Rupture
Stents
Tetrazoles
Thrombosis
Ticlopidine
Ultrasonics
Adenosine
Aspirin
Paclitaxel
Tetrazoles
Ticlopidine

Figure

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  Fig. 1 Initial coronary angiography in September 2004. A: thrombotic nearly total occlusion of the middle right coronary artery (RCA) (Type C, 99%, TIMI flow I). B: critical stenosis in the middle left anterior descending artery (LAD) (Type B2, 90%, TIMI flow III). C: 3.5×32 mm paclitaxel-eluting stent (Taxus Express II stent) was deployed in the RCA. D: 3.0×20 mm paclitaxel-eluting stent in the LAD. The final coronary angiography showed good distal flow without residual stenosis in both the coronary arteries. TIMI: Thrombolysis in Myocardial Infarction.

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  Fig. 2 Coronary angiography was performed 5 months later. No in-stent restenosis in the left anterior descending artery (A) and right coronary artery (B) stents were observed on follow-up coronary angiogram.

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  Fig. 3 A 12-lead electrocardiography showed ST-segment elevation in the lead II, III, aVF and Mobitz type II second degree atrioventricular block.

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  Fig. 4 A: right coronary angiogram showed very late stent thrombosis in the right coronary artery (RCA) stent. B: intravascular ultrasound (IVUS) showed neointimal rupture with thrombus within the RCA stent. C: coronary angiography after plain old balloon angioplasty. The final coronary angiogram showed good distal flow in the RCA. D: IVUS showed markedly decreased residual stenosis in the RCA.

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  Fig. 5 A: left coronary angiography showed mild type II in-stent restenosis in the left anterior descending artery (LAD). B: intravascular ultrasound revealed a plaque in the LAD stent.

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