Stent thrombosis treatment


 * Associate Editors-In-Chief: Smita Kohli, M.D.; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

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

The Underlying Cause of Stent Thrombosis Should Guide Management
The probable cause for stent thrombosis should be evaluated as the treatment varies with etiology.

Modifiable Procedural Related Causes
While the patient is undergoing cardiac catheterization, a careful evaluation should be undertaken to exclude procedure related variables that could be amenable to further treatment such as:
 * Suboptimal stent expansion and poor apposition,
 * Procedure-related variables of persistent dissection, total stent length, and final lumen diameter were significantly associated with the probability of stent thrombosis.

Modifiable Clinical Risk Factors
Likewise, the patient should be questioned thoroughly for the following clinical risk factors for stent thrombosis:
 * Noncompliance with dual antiplatelet therapy,
 * Premature discontinuation of dual antiplatelet therapy

Clopidogrel Resistance: a Clinical Diagnosis of Exclusion
If neither angiographic, procedural nor clinical variables appear to play a role, then clopidogrel resistance should be considered. This diagnosis can of course be confirmed through platelet function testing and genetic testing. If this is the case consideration should be made to switching the patient to prasugrel. The TIMI 38 or TRITON 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.