Treatment of coronary stent thrombosis

Associate Editor-In-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

Stents are usually placed in the proximal segments of major epicardial vessels, hence in-stent thrombotic occlusion clinically present as severe ischemia or infarction.

Management
Emergent target lesion or target vessel revascularization is the treatment of choice in stent thrombosis to restore vessel patency.
 * Revascularization may be carried out by PCI or in some instances, thrombolytics.


 * If revascularization is not successful, urgent CABG should be considered.


 * The probable cause for stent thrombosis should be evaluated as the treatment varies with etiology. The probable contributing factors are:
 * suboptimal stent apposition,
 * Procedure-related variables of persistent dissection, total stent length, and final lumen diameter were significantly associated with the probability of stent thrombosis.
 * premature discontinuation of dual antiplatelet therapy,
 * clopidogrel resistance.


 * If the patient develops stent thrombosis while on clopidogrel, it may suggest that the patient was not responsive to clopidrogrel therapy. TRITON TIMI 38 trial demonstrated that newer antiplatelet agents such as prasugrel may be used after weighing the risks of bleeding against benefits of decreased recurrence of stent thrombosis/coronary events.
 * Patients who present with stent thrombosis after completing the recommended duration of treatment with clopidogrel restarting clopidogrel 75 mg daily along with aspirin and continuing for a minimum of one year should be considered.