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Subacute Stent Thrombosis After Elective Stent Implantation in a Patient with Unstable Angina

- Operator: Myeong-Ki Hong, MD, PhD, Korea
Case presentation
A 60 year-old male was admitted for a recent onset of resting chest pain. He had 20 pack-year of smoking and hypertension as coronary risk factors. ECG showed ST depression on precordial leads. Echocardiography revealed a normal left ventricular function without regional wall motion abnormality.
Baseline coronary angiography
1. Coronary angiogram showed a tubular stenosis in the middle LAD (Figure 1).
2. The RCA and LCX were normal.

A 7F sheath was inserted through right femoral artery. The left coronary was engaged with a 7F Judkins catheter through the right femoral sheath. Coronary angiogram showed a tubular stenosis in the middle LAD. Predilatation with a 3.0x20 mm balloon at nominal pressure was done (Figure 2). After a predilatation (Figure 3), the lesion was stented with a Tsunami 3.0x20 mm stent at 10 atm (Figure 4). For angiographic stent optimization, a high pressure balloon dilatation was performed with the stent balloon at 14 atm (Figure 5). Final angiography showed a well deployed stent without residual stenosis or dissection and the presence of TIMI 3 flow (Figure 6). After the procedure, loading dose of clopidogrel (300mg) was given to the patient. Thereafter clopidogrel 75mg was administered once a day. The patient was discharged without any clinical event.

On the 7th days after the index procedure, the patient was presented to the emergency room with prolonged chest pain for 3 hours. EKG revealed ST elevation on precordial leads. Emergency coronary angiography was done for evaluation of chest pain. The angiography revealed a total occlusion of the stented site at the middle LAD with a TIMI 0 flow (Figure 7), which represented a subacute stent thrombosis. For emergent revascularization, a Choice PT wire was introduced into the LAD. And then, an Export catheter developed for aspiration of the intracoronary thrombus was used for reducing thrombus burden (Figure 8). After aspiration, following angiography revealed an improved TIMI flow in the lesion site (Figure 9). Thus balloon angioplasty was done with a 3.0x20 mm balloon at 10 atm (Figure 10). Final angiography showed a patent stent lumen without residual stenosis or dissection and the presence of a TIMI 3 flow (Figure 11). The hospital course was uneventful after procedure.

Maybe IVUS can help in terms of looking for the etiology of the subacute occlusion...malapposition of stent, dissection....etc. We have one patient with a possible resistance to clopidogrel ..in the IVUS we only find thrombus and the stent was OK mario araya..chile
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