Percutaneous coronary intervention (PCI) is one of the most common procedures performed in US and European hospitals. In the United States, 954,000 PCI procedures were performed in 2010, and in over 90% of these procedures, at least 1 coronary stent was implanted.1 Stent thrombosis (ST) is the most feared complication of coronary stenting and is characterized by rapid accumulation of thrombus within or adjacent to the stent. ST is typically associated with the abrupt onset of an acute coronary syndrome (ACS), manifesting as severe unstable angina, acute myocardial infarction, or sudden cardiac death. ST should be distinguished from progressive in-stent restenosis, resulting in eventual vessel occlusion, typically presenting as progressive exertional angina, but occasionally as ACS.2
In this chapter, we will review the classification of ST, the pathophysiology and predictors of ST, its consequences and treatment, and ongoing efforts to prevent this rare but major complication of percutaneous coronary revascularization. Data will be presented separately for bare metal stents (BMS; in aggregate for all types) and for first-generation (G1) and second-generation (G2) drug-eluting stents (DES). The G1-DES data refer specifically to paclitaxel-eluting stents (PES; Boston Scientific, Natick, MA) and sirolimus-eluting stents (SES; Cordis, Miami, FL), whereas G2-DES data reflect the experience accumulated predominantly with everolimus-eluting stents (EES; Abbott Vascular, Santa Clara, CA; or Boston Scientific), zotarolimus-eluting stents (Endeavor [E-ZES] and Resolute [R-ZES]; Medtronic, Santa Rosa, CA). All these DESs have durable polymers (Table 60-1). A special section is devoted to DESs with bioabsorbable polymers or polymer-free DESs and to bioresorbable vascular scaffolds toward the end of this review.
Table 60-1Properties of First- and Second-Generation Drug-Eluting Stents |Favorite Table|Download (.pdf) Table 60-1 Properties of First- and Second-Generation Drug-Eluting Stents
|Stent Name ||Manufacturer ||Scaffold ||Strut Thickness ||Polymer (thickness) ||Drug ||Elution in 1 Month |
|Cypher ||Cordis ||SS ||140 μm ||PEVA/PBMA (12.6 μm) ||Sirolimus ||98% |
|Taxus Liberte ||Boston Scientific ||SS ||97 μm ||PIB (16.0 μm) ||Paclitaxel ||7%-10% |
|Xience V ||Abbott Vascular ||CoCr ||81 μm ||PVDF-HFP/PBMA (7.8 μm) ||Everolimus ||80%a |
|Promus Element ||Boston Scientific ||PtCr ||81 μm ||PVDF-HFP/PBMA (7.8 μm) ||Everolimus ||80%a |
|Endeavor ||Medtronic ||CoCr ||91 μm ||PC (4 μm) ||Zotarolimus ||100% |
|Resolute ||Medtronic ||CoCr ||91 μm ||BioLinx (5.6 μm) ||Zotarolimus ||75%b |
CLASSIFICATION OF STENT THROMBOSIS
ST has been defined by the Academic Research Consortium (ARC) with respect to both its timing and certainty of its occurrence, in order to standardize interpretation of clinical trials and registries (Table 60-2).3 The ARC classification only considers events that occur after PCI is completed (after the patient has left ...