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Stent thrombosis (ST) is a feared complication post percutaneous coronary intervention (PCI), with associated morbidity and mortality. Variety of factors result in ST, majority of which are procedure / stent related. In view of these findings, patients presenting with ST should be investigated to identify underlying mechanism, before deciding management. However, no clear guidelines exist regarding ST management. Optical Coherence Tomography (OCT) offers the highest resolution among the present day intracoronary imaging modalities. We sought to perform OCT in each patient presenting with ST.
we identified 22 patients with ST out of 778 patients, who presented with ST elevation myocardial infarction at the University Hospital of Wales, Cardiff, UK. We obtained patient demographics, and index PCI procedural data by reviewing clinical charts. OCT was performed post thrombus aspiration and restoration of flow in the distal vessel. Patients with under-expanded or malapposed struts were treated by post-dilation, whereas those presenting with rupture of neoatherosclerotic lesion, were treated with additional stent deployment. We also performed OCT post-intervention to assess final result. Follow up data was obtained by reviewing clinical charts.
Time since index PCI ranged from 2 months to 8 years. Out of 22 patients, OCT demonstrated under-expanded struts in 16 patients, and well expanded but malapposed struts in 2 patients. Each of these patients was treated with POBA only. One of these patients demonstrated circumferential dissection at the distal end of the previously deployed stent on post-POBA OCT that was treated with stenting. Three patients had in-stent neointimal plaque rupture and were treated with stenting. One patient presented with second episode of ST; he also had a long segment of diffuse disease in the LAD, so he was referred for CABG. At a mean follow up of 12 months, these patients have remained asymptomatic, even after stopping DAPT. None of the patients experienced any major adverse cardiovascular events during the in-hospital stay.
1. Underlying mechanical problem is the most likely aetiology, resulting in ST.
2. OCT helps identifying underlying mechanism in patients presenting with ST.
3. Those with under-expanded / malapposed struts can be managed with POBA only.
4. OCT guided management should be implemented in each patient presenting with ST.
5. Larger randomized studies will be required to approve such a management strategy.