1. Use of OCT in Determining Dual Antiplatelet Treatment Duration
Ashish Shah, Timothy Kinnaird, Richard Anderson
University Hospital of Wales, Cardiff, UK

2. I/we have no real or apparent conflicts of interest to report.
Ashish H. Shah, MD, MRCP
I/we have no real or apparent conflicts of interest to report.

3. History 42 year – Female Presented with NSTEMI
Chronic immune-thrombocytopenic purpurra (ITP)
Since age of 22 years
Spleenectomy 1990
DVT (2010) – after immunoglobulin therapy
Treated with
Mycophenolate and prednisolone
Changed to rituximab
Azathioprine and prednisolone (present medication)
Gestational diabetes
Presented with NSTEMI
ECG – LAD syndrome

4. History and examination
General and systemic examination – Normal
Haemoglobin and white cell counts – Normal
Platelet count /ul
Required dual anti-platelet treatment
Haematologist consult
IV immunoglobulin – to increase platelet count
48 hours later – platelet count /ul
Underwent coronary angiography

5. Coronary angiogram

6. LCx

7. RCA

8. PCI

9. PCI

10. PCI

11. PCI

12. PCI to LAD Stented with 3.5 x 23 mm Genous stent
Antibody to CD-34 coated stent
Short duration of dual anti-platelet
1 week / 1 month
Low platelet count
Significant bruise
Discharged with Aspirin + clopidogrel
The coronary stent inserted in this patient was a Genous R-stentTM (OrbusNeich, Fort Lauderdale, FL, USA). This is a new bio-engineered stainless steel coronary artery stent coated with a biocompatible matrix covered with antibodies specific to CD34, a surface antigen present on circulating endothelial progenitor cells (EPCs). After stent insertion, these antibodies capture endogenous EPC from the circulation and these EPC mature into endothelial cells. This process causes endothelial healing to occur in a rapid and controlled manner, thus facilitating and accelerating the natural healing process and minimizing the time at which the stent surface is exposed to the risk of thrombosis. As a result of this rapid endothelialization, the manufacturers recommend only 4 weeks of dual antiplatelet therapy. However, these stents have been implanted with as little as 7 days clopidogrel treatment and varies at the discretion of the cardiologist. This obviously has potential advantages over traditional bare metal stents in patients who require urgent non-cardiac surgery with regard to the period when antiplatelet treatment is required. We believe this case adds to the current knowledge of coronary artery stents and highlights the importance of liaising with the cardiologists. These stents may be most useful in those patients who require urgent non-cardiac surgery. The initial trials of these stents56 seem promising but as ever we await the evaluation of long-term outcome studies.

13. Re-admission Advised to stop clopidogrel after 1 week
3 days after stopping clopidogrel
Further episode of chest pain
Anterior STEMI

14. Presented 10 days later with ant STEMI14

15. Thrombus - aspiration 15

16. PCI to LAD (in-stent thrombosis)16

17. PCI to LAD for IST 17

18. PCI to LAD for IST 18

19. PCI to LAD 19

20. Post PCI 20

21. PPCI for stent thrombosis
PCI with two 3.5 x 13 mm Genous stents
Aspirin + Ticagrelor
? Duration of DAPT 21

22. PCI (21st June) – OCT (30th July)22

23. OCT

24. Summary & conclusion What platelet count is acceptable - DAPT?
Dual anti-platelet treatment in ITP
What anti-platelet to use
? Platelet stimulant / anti-platelets
Increased risk of stent thrombosis
Special cohort – requiring multi-disciplinary management
OCT – helpful in deciding DAPT duration 24

25. Thank you for listening