1. Late stent thrombosis Ashish shah, Tim Kinnaird, W J Penny
University Hospital of Wales, Cardiff, UK

2. History 75 years old – retired physiotherapist
Hypertension, hypercholesterolemia
Refractory angina
PCI to LAD and LCx – 2008
PCI to prox-mid RCA – March – 09
3.5 x 13 mm Cypher (prox) and 3.0 x 33 mm Cypher stent (distally) with overlap
Post dilated with 3.5 mm NCB

3. PCI - 2009 2 2 1 Diagnostic angiography – LCx
Diagnostic angiography – LAD

4. PCI to mid RCA 2 1 Diagnostic angiography – RCA
3.0 x 33 mm Cypher stent in mid RCA

5. PCI to mid RCA 1 2
Balloon post dilatation of mid RCA – stented segment
3.5 x 13 mm Cypher in mid RCA; post dilated with 3.5 mm NCB

6. Final cine – March 09

7. Readmission Completely asymptomatic till Dec 12
Cutting log, walks 4-5 miles every day
While decorating Christmas tree
1st episode of chest pain and nauseated
ECG – Inferior STEMI
Primary PCI call activated

8. Diagnostic angiography – Dec 12
Diagnostic angiography – LCx
Diagnostic angiography - LAD

9. Occluded mid RCA 2 1 Diagnostic angiography – RCA
Post thrombus aspiration x 6

10. OCT – after thrombus aspiration1 2
Mean luminal area (MLA) – distal to stent – 7.8 mm2
MLA – distal part of stented segment – 5.5 mm2 ( post dilated with 3.5 mm NCB. Vessel measurement – 2.4 x 2.8 mm2)

11. Cine after thrombus aspiration
Cine post PCI

12. Post dilation with 3.75 mm NCB

13. Mean luminal area (MLA) – distal to stent – 7.7 mm2
OCT – post ballooning 1 2 2
Mean luminal area (MLA) – distal to stent – 7.7 mm2
MLA – distal part of stented segment – 10.1mm2 ( post dilated with 3.5 mm NCB. Vessel measurement – 3.5 x 3.7 mm2)

14. OCT of stented segment (Post POBA)1 1

15. Final cine

16. Summary Late stent thrombosis
Under expanded stent / long stent
Can be fatal
Important to understand / define mechanism
Check it post procedure (POBA / Stenting)
IVUS / OCT guided PCI

17. Conclusion
In each case of stent thrombosis – it is vital to know the underlying mechanism
Under-sized stent / poor expansion - apposition / long stent
Management strategy based upon the underlying problem
OCT – helps understanding mechanism very well 1 2