Abstract

Case Presentation

A patient with pulseless ST elevation myocardial infarction caused by a very late stent thrombosis

Masahiko Satoda* and Hiroaki Yusa

Published: 24 September, 2022 | Volume 7 - Issue 3 | Pages: 081-084

Background: Persistent contrast staining is highly associated with stent thrombosis. 
Case summary: A 75-year-old woman presented with new-onset effort angina. A coronary angiogram revealed a 90% blockage of the distal left main trunk (LMT) and a 99% blockage of the ostial left anterior descending coronary artery (LAD). A 3.0 × 18-mm CYPHER™ the stent had previously been implanted into the dominant proximal circumflex artery (LCx) in 2009 because of unstable angina. The patient developed pulseless ST elevation myocardial infarction after the withdrawal of antiplatelet therapy before a scheduled CABG. The patient recovered with 
VA-ECMO and PCI using aspiration thrombectomy and urgent CABG.
Discussion: This case highlighted that a preoperative patient may develop thrombosis at a previous stent site with peri-stent contrast staining and withdrawal of an antiplatelet regimen in certain settings poses an imminent risk for preoperative deterioration. A bridging strategy using intravenous PY12 inhibitor before CABG should be considered in this setting. The revascularization strategy should be selected based on coronary anatomy, hemodynamic status and baseline risk for CABG. A hybrid revascularization approach should be considered in this patient population.

Read Full Article HTML DOI: 10.29328/journal.jccm.1001138 Cite this Article Read Full Article PDF

Keywords:

ECMO; CPR; Aspiration thrombectomy; STEMI; Peri-stent contrast staining

References

  1. Imai M, Kadota K, Goto T, Fujii S, Yamamoto H, Fuku Y, Hosogi S, Hirono A, Tanaka H, Tada T, Morimoto T, Shiomi H, Kozuma K, Inoue K, Suzuki N, Kimura T, Mitsudo K. Incidence, risk factors, and clinical sequelae of angiographic peri-stent contrast staining after sirolimus-eluting stent implantation. Circulation. 2011 May 31;123(21):2382-91. doi: 10.1161/CIRCULATIONAHA.110.003459. Epub 2011 May 16. PMID: 21576652.
  2. Sullivan AE, Nanna MG, Wang TY, Bhatt DL, Angiolillo DJ, Mehran R, Banerjee S, Cantrell S, Jones WS, Rymer JA, Washam JB, Rao SV, Ohman EM. Bridging Antiplatelet Therapy After Percutaneous Coronary Intervention: JACC Review Topic of the Week. J Am Coll Cardiol. 2021 Oct 12;78(15):1550-1563. doi: 10.1016/j.jacc.2021.08.013. PMID: 34620413.
  3. Writing Committee Members, Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS Jr, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2021; S0735-1097(21)06157-X
  4. Thiele H, Ohman EM, de Waha-Thiele S, Zeymer U, Desch S. Management of cardiogenic shock complicating myocardial infarction: an update 2019. Eur Heart J. 2019 Aug 21;40(32):2671-2683. doi: 10.1093/eurheartj/ehz363. PMID: 31274157.
  5. Thiele H, Akin I, Sandri M, Fuernau G, de Waha S, Meyer-Saraei R, Nordbeck P, Geisler T, Landmesser U, Skurk C, Fach A, Lapp H, Piek JJ, Noc M, Goslar T, Felix SB, Maier LS, Stepinska J, Oldroyd K, Serpytis P, Montalescot G, Barthelemy O, Huber K, Windecker S, Savonitto S, Torremante P, Vrints C, Schneider S, Desch S, Zeymer U; CULPRIT-SHOCK Investigators. PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock. N Engl J Med. 2017 Dec 21;377(25):2419-2432. doi: 10.1056/NEJMoa1710261. Epub 2017 Oct 30. PMID: 29083953.
  6. Yukawa T, Kashiura M, Sugiyama K, Tanabe T, Hamabe Y. Neurological outcomes and duration from cardiac arrest to the initiation of extracorporeal membrane oxygenation in patients with out-of-hospital cardiac arrest: a retrospective study. Scand J Trauma Resusc Emerg Med. 2017 Sep 16;25(1):95. doi: 10.1186/s13049-017-0440-7. PMID: 28915913; PMCID: PMC5603067.
  7. Tada T, Kadota K, Hosogi S, Kubo S, Ozaki M, Yoshino M, Miyake K, Eguchi H, Ohashi N, Hayakawa Y, Saito N, Otsuru S, Hasegawa D, Shigemoto Y, Habara S, Imai M, Tanaka H, Fuku Y, Oka N, Kato H, Yamamoto H, Fujii S, Goto T, Mitsudo K. Optical coherence tomography findings in lesions after sirolimus-eluting stent implantation with peri-stent contrast staining. Circ Cardiovasc Interv. 2012 Oct;5(5):649-56. doi: 10.1161/CIRCINTERVENTIONS.112.968487. Epub 2012 Sep 25. PMID: 23011265.
  8. Ferraris VA, Saha SP, Oestreich JH, Song HK, Rosengart T, Reece TB, Mazer CD, Bridges CR, Despotis GJ, Jointer K, Clough ER; Society of Thoracic Surgeons. 2012 update to the Society of Thoracic Surgeons guideline on use of antiplatelet drugs in patients having cardiac and noncardiac operations. Ann Thorac Surg. 2012 Nov;94(5):1761-81. doi: 10.1016/j.athoracsur.2012.07.086. PMID: 23098967.
  9. Myles PS, Smith JA, Forbes A, Silbert B, Jayarajah M, Painter T, Cooper DJ, Marasco S, McNeil J, Bussières JS, Wallace S; ATACAS Investigators of the ANZCA Clinical Trials Network. Stopping vs. Continuing Aspirin before Coronary Artery Surgery. N Engl J Med. 2016 Feb 25;374(8):728-37. doi: 10.1056/NEJMoa1507688. PMID: 26933848.
  10. Rossini R, Masiero G, Fruttero C, Passamonti E, Calvaruso E, Cecconi M, Carlucci C, Mojoli M, Guido P, Talanas G, Pierini S, Canova P, De Cesare N, Luceri S, Barzaghi N, Melloni G, Baralis G, Locatelli A, Musumeci G, Angiolillo DJ. Antiplatelet Therapy with Cangrelor in Patients Undergoing Surgery after Coronary Stent Implantation: A Real-World Bridging Protocol Experience. TH Open. 2020 Dec 23;4(4):e437-e445. doi: 10.1055/s-0040-1721504. PMID:
  11. Sousa-Uva M, Head SJ, Milojevic M, Collet JP, Landoni G, Castella M, Dunning J, Gudbjartsson T, Linker NJ, Sandoval E, Thielmann M, Jeppsson A, Landmesser U. 2017 EACTS Guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg. 2018 Jan 1;53(1):5-33. doi: 10.1093/ejcts/ezx314. PMID: 29029110.
  12. Kaldırım U, Toygar M, Karbeyaz K. Complications of cardiopulmonary resuscitation in nontraumatic cases and factors affecting complications. Egypt J Forensic Sci 2016; 6:270–274.
  13. Yunoki K, Naruko T, Inoue T, Sugioka K, Inaba M, Iwasa Y, Komatsu R, Itoh A, Haze K, Yoshiyama M, Becker AE, Ueda M. Relationship of thrombus characteristics to the incidence of angiographically visible distal embolization in patients with ST-segment elevation myocardial infarction treated with thrombus aspiration. JACC Cardiovasc Interv. 2013 Apr;6(4):377-85. doi: 10.1016/j.jcin.2012.11.011. Epub 2013 Mar 20. PMID: 23523458.
  14. Nichols EL, McCullough JN, Ross CS, Kramer RS, Westbrook BM, Klemperer JD, Leavitt BJ, Brown JR, Olmstead E, Hernandez F, Sardella GL, Frumiento C, Malenka D, DiScipio A; Northern New England Cardiovascular Disease Study Group. Optimal Timing From Myocardial Infarction to Coronary Artery Bypass Grafting on Hospital Mortality. Ann Thorac Surg. 2017 Jan;103(1):162-171. doi: 10.1016/j.athoracsur.2016.05.116. Epub 2016 Aug 25. PMID: 27570160.
  15. Smilowitz NR, Alviar CL, Katz SD, Hochman JS. Coronary artery bypass grafting versus percutaneous coronary intervention for myocardial infarction complicated by cardiogenic shock. Am Heart J. 2020 Aug;226:255-263. doi: 10.1016/j.ahj.2020.01.020. Epub 2020 Mar 12. PMID: 32278440; PMCID: PMC7442583.
  16. https://openredcap.nyumc.org/apps/redcap/surveys/index.php?s=NLH44N9DN9

Figures:

Figure 1

Figure 1

Figure 1

Figure 2

Figure 1

Figure 3

Figure 1

Figure 4

Figure 1

Figure 5

Similar Articles

Recently Viewed

Read More

Most Viewed

Read More

Help ?