Author + information
- Received January 6, 2014
- Revision received February 18, 2014
- Accepted February 24, 2014
- Published online June 17, 2014.
- Masataka Nakano, MD∗,
- Kazuyuki Yahagi, MD∗,
- Fumiyuki Otsuka, MD, PhD∗,
- Kenichi Sakakura, MD∗,
- Aloke V. Finn, MD†,
- Robert Kutys, MS∗,
- Elena Ladich, MD∗,
- David R. Fowler, MD‡,
- Michael Joner, MD∗ and
- Renu Virmani, MD∗∗ ()
- ∗CVPath Institute, Gaithersburg, Maryland
- †Department of Medicine, Emory University Hospital, Atlanta, Georgia
- ‡Office of the Chief Medical Examiner, Baltimore, Maryland
- ↵∗Address correspondence to:
Dr. Renu Virmani, CVPath Institute, Inc., 19 Firstfield Road, Gaithersburg, Maryland 20878.
Objectives The study interrogated an autopsy registry to investigate the histopathologic features of early stent thrombosis (ST) in patients presenting with acute coronary syndrome (ACS).
Background The occurrence of early ST following percutaneous coronary intervention (PCI) for ACS remains a clinical problem despite advances in stent technology in both bare-metal and drug-eluting stents.
Methods Sixty-seven stented coronary lesions from 59 patients who presented with ACS and died within 30 days were included. Stented segments were cross sectioned at 3 to 4 mm intervals and evaluated by light microscopy, and morphometric analysis was performed.
Results Early ST (<30 days of PCI) was identified in 34 (58%) of the 59 patients. Early ST was dependent on the underlying plaque morphology and underlying thrombus burden: presence of necrotic core prolapse was more frequent in thrombosed lesions compared with patent lesions (70% vs. 43%, p = 0.045) and maximal underlying thrombus thickness was significantly greater in thrombosed versus patent lesions. All 3 patients with false lumen stenting had ST. Detailed analysis revealed that the percent of necrotic core prolapse, medial tear, or incomplete apposition was significantly greater in the early ST compared with patent group (28% vs.11%, p < 0.001; 27% vs. 15% p = 0.004; and 34% vs. 18% p = 0.008, respectively). Multivariate analysis revealed that maximal depth of strut penetration, % strut with medial tear, and % struts with incomplete apposition were the primary indicators of early ST.
Conclusions The current autopsy study highlights the impact of thrombus burden and suboptimal stent implantation in unstable lesions as a trigger of early ST, suggesting that improvement in implantation technique and refinement of stent design may improve clinical outcomes of ACS patients.
- acute coronary syndrome(s)
- bare-metal stent(s)
- drug-eluting stent(s)
- early stent thrombosis
This work was in part supported by an educational research grant from Stentys Inc. (Princeton, New Jersey) but the manuscript was prepared independently by CVPath Institute Inc. (Gaithersburg, Maryland), a private nonprofit research organization. Dr. Sakakura has received speaking honoraria from Abbott Vascular, Boston Scientific, and Medtronic CardioVascular. Dr. Finn is supported by the NIH grant HL096970-01A1, the American Heart Association, the Woodruff Sciences Health Center, and Carlyle Fraser Heart Center both at Emory University; has a sponsored research agreement with Medtronic and Boston Scientific; is a consultant for Medtronic; and serves on the Medtronic Advisory Board. Dr. Joner is a consultant for Biotronik and Cardionovum; has received speaking honoraria from Abbott Vascular, Biotronik, Medtronic, and St. Jude Medical; and has received educational grant support from Biotronik and St. Jude Medical. Dr. Virmani has received research support from Abbott Vascular, Atrium, BioSensors International, Biotronik, Boston Scientific, CeloNova, Cordis Johnson&Johnson, GlaxoSmithKline, Kona Medical, Medtronic, MicroPort Medical, OrbusNeich Medical, ReCor Medical, SINO Medical Technology, Terumo Corporation, W.L. Gore, and 480 Biomedical; has speaking engagements with Merck & Co., Inc.; has received honoraria from Abbott Vascular, Biosensors International, Boston Scientific, CeloNova, Cordis Johnson&Johnson, Lutonix, Medtronic, Terumo Corporation, W.L. Gore, and 480 Biomedical; and is a consultant for 480 Biomedical, Abbott Vascular, Medtronic, and W.L. Gore. CVPath Institute has research grants from Abbott Vascular, Biosensors International, Boston Scientific, Cordis/Johnson&Johnson, Medtronic CardioVascular, OrbusNeich Medical, and Terumo Corporation. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Nakano and Yahagi contributed equally to this work.
- Received January 6, 2014.
- Revision received February 18, 2014.
- Accepted February 24, 2014.
- 2014 American College of Cardiology Foundation