ContextTraditionally, stent thrombosis has been regarded as a complication
of percutaneous coronary interventions during the first 30 postprocedural
days. However, delayed endothelialization associated with the implantation
of drug-eluting stents may extend the risk of thrombosis beyond 30 days. Data
are limited regarding the risks and the impact of this phenomenon outside
clinical trials.ObjectiveTo evaluate the incidence, predictors, and clinical outcome of stent
thrombosis after implantation of sirolimus-eluting and paclitaxel-eluting
stents in routine clinical practice.Design, Setting, and PatientsProspective observational cohort study conducted at 1 academic hospital
and 2 community hospitals in Germany and Italy. A total of 2229 consecutive
patients underwent successful implantation of sirolimus-eluting (1062 patients,
1996 lesions, 2272 stents) or paclitaxel-eluting (1167 patients, 1801 lesions,
2223 stents) stents between April 2002 and January 2004.InterventionsImplantation of a drug-eluting stent (sirolimus or paclitaxel). All
patients were pretreated with ticlopidine or clopidogrel and aspirin. Aspirin
was continued indefinitely and clopidogrel or ticlopidine for at least 3 months
after sirolimus-eluting and for at least 6 months after paclitaxel-eluting
stent implantation.Main Outcome MeasuresSubacute thrombosis (from procedure end through 30 days), late thrombosis
(>30 days), and cumulative stent thrombosis.ResultsAt 9-month follow-up, 29 patients (1.3%) had stent thrombosis (9 [0.8%]
with sirolimus and 20 [1.7%] with paclitaxel; P = .09).
Fourteen patients had subacute thrombosis (0.6%) and 15 patients had late
thrombosis (0.7%). Among these 29 patients, 13 died (case fatality rate, 45%).
Independent predictors of stent thrombosis were premature antiplatelet therapy
discontinuation (hazard ratio [HR],  89.78; 95% CI, 29.90-269.60; P<.001), renal failure (HR,  6.49; 95% CI,
2.60-16.15; P<.001), bifurcation lesions (HR,  6.42;
95% CI, 2.93-14.07; P<.001), diabetes (HR,  3.71;
95% CI, 1.74-7.89; P = .001), and a lower
ejection fraction (HR,  1.09; 95% CI, 1.05-1.36; P<.001 for each 10% decrease).ConclusionsThe cumulative incidence of stent thrombosis 9 months after successful
drug-eluting stent implantation in consecutive “real-world” patients
was substantially higher than the rate reported in clinical trials. Premature
antiplatelet therapy discontinuation, renal failure, bifurcation lesions,
diabetes, and low ejection fraction were identified as predictors of thrombotic
events.

https://jamanetwork.com/journals/jama/articlepdf/200798/JBR50003.pdf

Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents.

Alice K. Jacobs, MD, FACC, FAHA, Chair 

Jeffrey L. Anderson, MD, FACC, FAHA, Chair-Elect 

Nancy Albert, PhD, CCNS, CCRN, FAHA

Mark A. Creager, MD, FACC, FAHA

Steven M. Ettinger, MD, FACC

Robert A. Guyton, MD, FACC

Jonathan L. Halperin, MD, FACC, FAHA

Judith S. Hochman, MD, FACC, FAHA

2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions

http://www.botonimarco.it/files/linee_guida_2011_accf_aha_scai_percutaneus_coronar.pdf

2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention

The American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions (ACC/AHA/SCAI) 2005 Guideline Update for Percutaneous Coronary Intervention (PCI) contains changes in the recommendations, along with supporting text. For the purpose of comparison

https://cdr.lib.unc.edu/downloads/k3569637k

ACC/AHA/SCAI 2005 Guideline Update for Percutaneous Coronary Intervention-summary article : A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention)

https://cdr.lib.unc.edu/downloads/9p290c48k

ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery)

To assess the likelihood of procedural success in patients with multivessel coronary disease undergoing percutaneous coronary angioplasty, 350 consecutive patients (1,100 stenoses) from four clinical sites were evaluated. Eighteen variables characterizing the severity and morphology of each stenosis and 18 patient-related variables were assessed at a core angiographic laboratory and at the clinical sites. Most patients had Canadian Cardiovascular Society class III or IV angina (72%) and two-vessel coronary disease (78%). Left ventricular function was generally well preserved (mean ejection fraction, 58 +/- 12%; range, 18-85%) and 1.9 +/- 1.0 stenoses per patient had attempted percutaneous coronary angioplasty. Procedural success (less than or equal to 50% final diameter stenosis in one or more stenoses and no major ischemic complications) was achieved in 290 patients (82.8%), and an additional nine patients (2.6%) had a reduction in diameter stenosis by 20% or more with a final diameter stenosis 51-60% and were without major complications. Major ischemic complications (death, myocardial infarction, or emergency bypass surgery) occurred in 30 patients (8.6%). In-hospital mortality was 1.1%. Stepwise regression analysis determined that a modified American College of Cardiology/American Heart Association Task Force (ACC/AHA) classification of the primary target stenosis (with type B prospectively divided into type B1 [one type B characteristic] and type B2 [greater than or equal to two type B characteristics]) and the presence of diabetes mellitus were the only variables independently predictive of procedural outcome (target stenosis modified ACC/AHA score; p less than 0.001 for both success and complications; diabetes mellitus: p = 0.003 for success and p = 0.016 for complications). Analysis of success and complications on a per stenosis dilated basis showed, for type A stenoses, a 92% success and a 2% complication rate; for type B1 stenoses, an 84% success and a 4% complication rate; for type B2 stenoses, a 76% success and a 10% complication rate; and for type C stenoses, a 61% success and a 21% complication rate. The subdivision into types B1 and B2 provided significantly more information in this clinically important intermediate risk group than did the standard ACC/AHA scheme. The stenosis characteristics of chronic total occlusion, high grade (80-99% diameter) stenosis, stenosis bend of more than 60 degrees, and excessive tortuosity were particularly predictive of adverse procedural outcome. This improved scheme may improve clinical decision making and provide a framework on which to base meaningful subgroup analysis in randomized trials assessing the efficacy of percutaneous coronary angioplasty.

Coronary morphologic and clinical determinants of procedural outcome with angioplasty for multivessel coronary disease. Implications for patient selection. Multivessel Angioplasty Prognosis Study Group.

BACKGROUNDTo assess the likelihood of intermediate-term event-free survival (freedom from death, coronary artery bypass surgery, and myocardial infarction) in patients with multivessel coronary disease undergoing coronary angioplasty, 350 consecutive patients from four clinical sites were carefully evaluated and followed for 22 +/- 10 months.METHODS AND RESULTSEight clinical variables were evaluated at the clinical sites, and 23 angiographic variables describing the number, morphology, and topography of coronary stenoses were evaluated at a core angiographic laboratory. Most patients had Canadian Cardiovascular Society class III or IV angina (72%), two-vessel coronary disease (68%), and well-preserved left ventricular function (mean ejection fraction, 58 +/- 12%; range, 18-85%). Follow-up was complete in 99% of patients. At 2 years, event-free survival was 72%, overall survival was 96%, freedom from bypass surgery was 82%, and freedom from nonfatal myocardial infarction without surgery was 96%. Sequential...

Determinants of 2-year outcome after coronary angioplasty in patients with multivessel disease on the basis of comprehensive preprocedural evaluation. Implications for patient selection. The Multivessel Angioplasty Prognosis Study Group.

Ubeydullah Deligonul

Papers

Coronary morphologic and clinical determinants of procedural outcome with angioplasty for multivessel coronary disease. Implications for patient selection. Multivessel Angioplasty Prognosis Study Group.

Determinants of 2-year outcome after coronary angioplasty in patients with multivessel disease on the basis of comprehensive preprocedural evaluation. Implications for patient selection. The Multivessel Angioplasty Prognosis Study Group.