Use of drug eluting stents has become the state-of-the-art therapy for percutaneous treatment of obstructive coronary artery disease. However, concern has been expressed on the delayed healing after implantation of a drug eluting stent. We present the first report of late thrombotic occlusion of a paclitaxel eluting stent (Taxus, Boston Scientific Corp) at just more than one year after implantation.
A 44 year old Indian man underwent implantation of a 3.0/24 mm paclitaxel eluting stent on 27 September 2002 for treatment of unstable angina caused by proximal left anterior descending (LAD) artery stenosis. Long term aspirin and six months of clopidogrel were prescribed, together with anti-lipid treatment. The patient was compliant but continued to smoke. He remained well until 8 October 2003 when he presented with chest pain for three hours, associated with diaphoresis. A 12 lead ECG showed ST segment elevation consistent with acute anterior myocardial infarction. Emergency coronary angiography confirmed a totally occluded proximal LAD artery, the site of the paclitaxel eluting stent (panel A). The occlusion was crossed using a 0.014 inch floppy guidewire, with immediate restoration of antegrade TIMI grade 2 flow. Heavy thrombus burden was noted in-stent. A PercuSurge Export aspiration catheter was used to aspirate the thrombus (lower left panel). Intravascular ultrasound (lower right panel) showed only mild in-stent neointimal hyperplasia, suggesting primarily a thrombotic event. The stent was well expanded except for a small segment at the proximal stent edge. No stent malapposition or edge stenosis was noted. A 3.0/10 mm cutting balloon, and then a 3.25/15 mm NC monorail balloon was used to dilate the stent in sequence. The procedure was performed with the support of double bolus intracoronary doses of eptifibatide, given 10 minutes apart, followed by continuous intravenous infusion for 48 hours. Final angiography (panel B) showed < 10% residual stenosis, TIMI 3 flow and myocardial blush grade 3
Figure 1.
(A) Diagnostic angiography showed total occlusion of the paclitaxel eluting stent (arrow). (B) Final angiography after thrombus aspiration and balloon dilatation of the stent showed normal antegrade flow (TIMI 3).
Figure 2.
Thrombus aspirated by the PercuSurge Export aspiration catheter.
Figure 3.
Intravascular ultrasound image of the stent after thrombus aspiration. The stent was well expanded and apposed. No significant in-stent neointimal hyperplasia was detected.