An elderly case with late carotid stent thrombosis: possible role of antiphospholipid antibodies

The case study speculates that the antiphospholipid antibodies acquired during the follow-up period of carotid artery stenting may cause late stent thrombosis that is resistant to direct oral anticoagulants. A 73-year-old man was hospitalized with complaints of weakness in the right lower extremity. The patient had undergone carotid artery stenting for symptomatic stenosis of the left internal carotid artery 6 years prior and had received antiplatelet therapy with clopidogrel 75 mg/day. As the patient had developed atrial fibrillation without stent stenosis at the age of 70 years, anticoagulation therapy with rivaroxaban15 mg/day was initiated while discontinuing clopidogrel. On admission, diffusion weighted imaging (DWI) revealed acute brain infarcts in the territory of the left middle cerebral artery. Contrast-enhanced computed tomography and cerebral angiography exposed severe stenosis in the left carotid artery accompanied by a filling defect caused by a floating thrombus. Laboratory examination revealed the presence of three types of antiphospholipid antibodies, with marked prolongation of activated partial thromboplastin time (APTT). Replacement of rivaroxaban with warfarin eliminated the thrombus without recurrent stroke. In conclusion, late stent thrombosis may be associated with antiphospholipid antibodies acquired during the follow-up period of carotid artery stenting.

Inhibition of mitochondrial complex I leading to NAD+/NADH imbalance in type 2 diabetic patients who developed late stent thrombosis: Evidence from an integrative analysis of platelet bioenergetics and metabolomics

Type 2 diabetes mellitus (T2DM) is a strong indicator of late stent thrombosis (LST). Platelet bioenergetic dysfunction, although critical to the pathogenesis of diabetic macrovascular complications, remains uncharacterized in T2DM patients who developed LST. Here, we explored the mechanistic link between the alterations in platelet bioenergetics and LST in the setting of T2DM. Platelet bioenergetics, metabolomics, and their interactomes were analyzed in a nested case-control study including 15 T2DM patients who developed LST and 15 matched T2DM patients who did not develop LST (non-LST). Overall, we identified a bioenergetic alteration in T2DM patients with LST characterized by an imbalanced NAD+/NADH redox state resulting from deficient mitochondrial complex I (NADH: ubiquinone oxidoreductase) activity, which led to reduced ATP-linked and maximal mitochondrial respiration, increased glycolytic flux, and platelet hyperactivation compared with non-LST patients. Congruently, platelets from LST patients exhibited downregulation of tricarboxylic acid cycle and NAD+ biosynthetic pathways as well as upregulation of the proximal glycolytic pathway, a metabolomic change that was primarily attributed to compromised mitochondrial respiration rather than increased glycolytic flux as evidenced by the integrative analysis of bioenergetics and metabolomics. Importantly, both bioenergetic and metabolomic aberrancies in LST platelets could be recapitulated ex vivo by exposing the non-LST platelets to a low dose of rotenone, a complex I inhibitor. In contrast, normalization of the NAD+/NADH redox state, either by increasing NAD+ biosynthesis or by inhibiting NAD+ consumption, was able to improve mitochondrial respiration, inhibit mitochondrial oxidant generation, and consequently attenuate platelet aggregation in both LST platelets and non-LST platelets pretreated with low-dose rotenone. These data, for the first time, delineate the specific patterns of bioenergetic and metabolomic alterations for T2DM patients who suffer from LST, and establish the deficiency of complex I-derived NAD+ as a potential pathogenic mechanism in platelet abnormalities.

Meta-analysis of Duration of Continuous Dual Antiplatelet Therapy and Late Stent Thrombosis After Second-Generation Drug Stent Implantation

INTRODUCTION

The aim of the present study was to perform a systematic comparison of the incidence of late and extremely late stent thrombosis (ST) with short-term and long-term dual antiplatelet therapy (DAPT) after a second-generation drug-eluting stent (DES) implantation.

METHODS

Randomized controlled trials using short-term and long-term DAPT and reporting late ST (30 days-1 year) and extremely late ST (longer than 1 year) after a percutaneous coronary intervention (PCI) with DES were searched and compared in the Life Sciences and Biomedical Information Bibliographic Database (MEDLINE), EMBASE, Cochrane Central, and ClinicalTrials.com. ST was used as the primary endpoint of the therapeutic outcome, and the fixed-effects model (I² < 50%) or random-effects model (I² ≥ 50%) was adopted for the combined analysis. The odds ratio (OR) and 95% confidence interval (CIs) were used to represent the results. P < 0.05 in the combined result indicated that the difference was statistically significant.

RESULTS

A total of five randomized controlled trials consisting of 7142 patients were included, with 3556 cases of short-term DAPT (at most 6 months), and 3586 cases of long-term DAPT (at least 12 months). There was no significant difference between late ST and administration duration of DAPT (OR 0.98, 95% CI 0.30-3.18; P = 0.97, I² = 0%). There was also no significant difference between the incidence of extremely late ST and the duration of DAPT application (OR 0.30, 95% CI 0.03-2.95; P = 0.31).

CONCLUSION

The duration of continuous DAPT application had no effect on the occurrence of late and extremely late ST.

Duration of Dual Antiplatelet Therapy and Late Stent Thrombosis Following Percutaneous Coronary Intervention with Second-Generation Drug-Eluting Stents: A Simple Meta-Analysis of Randomized Controlled Trials

Introduction

The aim of this simple meta-analysis was to systematically compare the occurrence of late and very late stent thrombosis with a short versus a longer duration of dual anti-platelet therapy (DAPT) use following the implantation of second-generation drug-eluting stents (DES).

Methods

Randomized controlled trials that compared short- and long-term DAPT use following percutaneous coronary intervention (PCI) with DES and that reported late (> 30 days but < 1 year) and very late (> 1 year) stent thromboses were searched from the bibliographic database of life sciences and biomedical information, which is also known as MEDLINE, as well as other searched databases including EMBASE, the Cochrane Central and http://www.ClinicalTrials.com. Statistical analysis was carried out using RevMan software [odds ratios (OR) and 95% confidence intervals (CIs) represented the results].

Results

This simple analysis consisted of five randomized controlled trials with a total of 7142 patients. The current results showed no significant difference in late stent thrombosis associated with a shorter or longer duration of DAPT use (OR 0.98, 95% CI 0.30–3.18; P = 0.97, I² = 0%). The result for very late stent thrombosis was also not significantly different (OR 0.30, 95% CI 0.03–2.95; P = 0.31).

Conclusions

This simple analysis showed no impact of DAPT duration on the occurrence of late and very late stent thrombosis. Similar late and very late stent thrombosis rates were observed with 6-month versus 12-month duration of DAPT use following PCI with second-generation DES.

Failure of drug-coated balloon angioplasty to treat bare metal in-stent restenosis accompanied by late stent thrombosis but successful treatment of binary in-stent restenosis

Drug-coated balloons (DCB) are effective in treating in-stent restenosis (ISR) with neointimal proliferation after bare-metal stent (BMS) implantation, but it is unclear whether DCB are effective in treating BMS-ISR accompanied by thrombosis. An 84-year-old man with previous inferior myocardial infarction and atrial fibrillation developed acute myocardial infarction (AMI) during hospitalization for intracerebral hemorrhage. Emergent coronary angiography (CAG) revealed severe stenosis of the distal left circumflex coronary artery. We implanted a BMS to avoid long-term triple antithrombotic therapy. He received aspirin, clopidogrel, and rivaroxaban for 1 month and then received clopidogrel and rivaroxaban. Seventy days after BMS implantation, he developed AMI, and emergent CAG revealed occlusion of the BMS due to late stent thrombosis. After thrombus aspiration, intravascular ultrasound showed incomplete neointimal healing in the proximal portion of the stent and excessive neointimal proliferation in the distal portion of the stent. DCB angioplasty of the entire BMS was performed after scoring balloon pre-dilation. Seven months after BMS implantation, follow-up CAG revealed binary ISR. DCB angioplasty of the entire BMS was performed again after scoring balloon pre-dilation. Thirteen months after BMS implantation, follow-up CAG did not reveal recurrence of ISR. <Learning objective: Drug-coated balloons (DCB) were ineffective when there was excessive neointimal proliferation accompanied by thrombosis, but effective in binary in-stent restenosis (ISR). DCB may be ineffective in early ISR after bare-metal stent implantations and when there is excessive neointimal proliferation accompanied by thrombosis. Since the safety and efficacy of DCB to treat excessive neointimal proliferation occurring with late stent thrombosis is unclear, further studies are needed.>.

Early (≤ 30 Days), Late (31-360 Days) and Very Late (> 360 Days) Stent Thrombosis in Patients with Insulin-Treated versus Non-Insulin-Treated Type 2 Diabetes Mellitus: A Meta-Analysis

INTRODUCTION

At this time in 2018, with type 2 diabetes mellitus (T2DM) and coronary artery disease (CAD) still on the rise, the post-percutaneous coronary interventional (PCI) outcomes observed in patients with diabetes mellitus who are on insulin therapy (ITDM) and those who do not require insulin (NITDM) are still controversial and require further investigation. Considering this idea to be of particular interest to the readers, as well as being an important issue in interventional cardiology, we aimed to systematically assess early (≤ 30 days), late (31-360 days) and very late (> 360 days) stent thrombosis in patients with ITDM and NITDM following drug-eluting stent (DES) implantation.

METHODS

Well-known online databases (the Cochrane, EMBASE and MEDLINE databases and http://www.ClinicalTrials.gov ) were searched for relevant English publications based on ITDM and NITDM and stent thrombosis following PCI using specific terms. Early stent thrombosis, late stent thrombosis and very late stent thrombosis were the clinical outcomes. The main analysis was carried out using the latest version of the RevMan software (version 5.3) whereby odds ratios (OR), and 95% confidence intervals (CI) were generated.

RESULTS

A total of 8524 participants with T2DM (2273 participants were on insulin therapy and 6251 participants were not) were included. Results of this analysis showed early stent thrombosis to be significantly higher in patients with ITDM (OR 1.81, 95% CI 1.04-3.15; P = 0.04), whereas late and very late stent thromboses were not significantly different following PCI with DES in diabetic patients with versus without insulin therapy (OR 1.44, 95% CI 0.73-2.84, P = 0.30 and OR 0.80, 95% CI 0.33-1.92, P = 0.62, respectively). Late stent thromboses associated exclusively with everolimus-eluting stents (EES) and paclitaxel-eluting stents (PES) were not significantly different in patients with ITDM and NITDM.

CONCLUSION

Following PCI with DES, early stent thrombosis was significantly higher in patients with ITDM. However, late and very late stent thromboses were not significantly different in patients with type 2 diabetes mellitus who were treated with or without insulin. Comparison with individual DES was not sufficiently powerful to reach a conclusion.

Subclinical very late thrombus formation inside and outside the everolimus-eluting stent implanted 3 years prior in a patient with provoked coronary spasms

A 63-year-old man with non-ST-elevation acute myocardial infarction had undergone PROMUS Element stent implantation for stenosis with thrombus in the left main trunk and the proximal left anterior descending artery. A 6-month follow-up angiography revealed no restenosis or stent thrombosis, but severe provoked spasms in three vessels, for which medications were administered. Three years later, the patient experienced new-onset rest angina one morning. Optical coherence tomography revealed subclinical very late stent thromboses inside and outside the stent. The patients experienced a severe spasm. Platelet function was adequately reduced, and the cytochrome P450 2C19 genotype indicated an extensive metabolizer phenotype. The spasm may have caused the thromboses.

Late stent thrombosis after discontinuation of dual anti-platelet therapy in off-label use of paclitaxel-eluting stent visualized by optical coherence tomography-3-vessel OCT study

We observed late stent thrombosis image by optical coherence tomography (OCT) in vessels with off-label paclitaxel-eluting stents (PES) implantation. A 59-year-old Japanese man was treated with a single on-label PES for chronic coronary artery disease in the left circumflex artery. After 9 months, he was implanted with two linked PESs in the left anterior descending artery (LAD) and a single PES in the right coronary artery (RCA). He was examined for suspicion of a colon tumor by fiberscope after discontinuation of dual anti-platelet therapy without consultation. He complained of chest pain and was transferred to our center. Emergency coronary angiography demonstrated thrombotic total occlusion of the proximal LAD in the two linked PESs. After thrombus aspiration therapy, OCT was performed to evaluate the stents in the 3 vessels. The off-label two linked PESs demonstrated the same average neo-intimal hyperplasia (NIH) thickness and percentage of uncovered stent struts compared with the on-label PES in the RCA by visualized OCT image. However, the heterogeneity of NIH in the LAD stent was significantly higher than the stents in the other two vessels. The implantation of the two linked off-label and the heterogeneity of NIH may increase hyperplatelet coagulability more than on-label single PES use.