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A Case of Late Total Occlusion after Sirolimus-Eluting Stent Implantation

- Operator: Myeong-Ki Hong, MD

Case presentation

A 34-year old woman had undergone sirolimus-eluting stent (Cypher, Cordis) implantation for stable angina in June 2003. Her initial coronary angiogram showed diffuse narrowing of the proximal left anterior descending artery (LAD) (Image 1, Image 2). Two 3.5 x 33 mm Cypher stents were successfully implanted to treat the lesion (Image 3, Image 4). She had been symptom-free state thereafter and the 6-month follow-up coronary angiogram in December 2003 showed patent stents in LAD (Image 5, Image 6). But, she was admitted due to recurred angina in July 2005 and the 2-year follow-up coronary angiogram showed total occlusion of the LAD stents (Image 7, Image 8, Image 9). As an antiplatelet regimen, only the aspirin had been administered without combination of clopidogrel. Because the lesion length is too long to be treated with percutaneous intervention, she underwent bypass surgery and has been asymptomatic.

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Roberto Baglini2005-12-03
This can be a case of late stent thrombosis. I am convinced that as the long term follow up of DES will start to be substantial a significant number of these cases will be discovered. Unfortunately their endothelium tossicity could reserve a lot of surprise in the future. In this particular case the post procedure tretament with only aspirin could have precipitated LST.
Cheng zhenfeng2005-12-05
Clopidogrel is very expensive for the patients after PCI in China, but we prescribe for them ordinarily before and after stent implanted.
Bong-Ki Lee2005-12-06
We routinely use plavix at least for 6 months after stent implantation. And, we agree to Dr. Roberto's opinion. It is certain that there are substantial stent thrombosis after DES implantation is a serious problem.
Dr.Pramod Jaiswal2005-12-09
Most likely cause is late stent thrombosis. In a recent article in JACC from Dr. Patric Surrays group, they have reported cases of LAST (late angiographic stent thrombosis) occurring as late as two years following DES implantation. Some of these patients presented with acute MI. As of now, it seems that continuing Clopidogrel indefinitely is the safest strategy if cost is not a problem and there is no contraindication.
pogolerich2005-12-09
It is a rare case about DES to be totally occlusive only within 2 years. In my opinion, 6 months using of Plavix may not be enough and I will suggest my patient to buy the drug and take it for at least one year.
Joy M. Thomas2005-12-13
I agree with Dr Pramod Jaiswal. I have all my patients on clopidogrel for life, as long as there is no contraindication. The cost is negligible compared to the agony and cost of another procedure- surgical or PCI.
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