BASICS Meeting , 23rd April  2015, Belgrade PRESENTATION: Nicolas Amabile, MD, PhD, Cardiology department, Institut Mutualiste

Conflict of interest : Dr Nicolas Amabile, received some consulting fees from St Jude Medical, Boston Scientific and Astra Zeneca.

Cliquer sur les images pour agrandir / Click images to enlarge

A 75 years old man was referred to our center for acute lateral STEMI.

Previous Medical History:

Dyslipidemia under statin therapy

Previous PCI  (9 years before) on Dg1 with DES (Cypher° 2.5 x 18 mm) for stable angina

Antiplatelet therapy : aspirin 75mg/d since 2003

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Initial Coronary Angiography following successful thrombolysis

CASE FINDINGS

Extremely late drug eluting stent thrombosis

Correct struts coverage of the distal part of the stent.

Evidences of uncovered + malapposed struts  on the proximal part of the stent.

Probable late-acquired malapposition of the Cypher Device.

Treatment:

Medical therapy : Initial Anticoagulation (LMWH) + Double APT (ticagrelor+ aspirin)

Prolonged DAPT after Hospital discharge

Is stent thrombosis still an issue ?

ST is a multifaceted process

What can we expect from OCT in ST ?

To assess the diagnosis

To identify the underlying mechanism

To guide treatment.

Ruptured Neoatheroma

Malapposition

Evaginations

Underexpansion

Isolated uncovered struts

Edge related disease progression

ISR without neoatheroma

Edge dissection

What do the studies tell us ?

Neoatherosclerosis in VLST

N=33 patients with VLST (52% STEMI, 33% NSTEMI, 15% UA)

OCT analysis before thrombus aspiration

What about the “big picture” ?

According to the operators, ST mechanism could be certainly assessed by coronary angiography alone in  14 % of the patients

Does OCT use change ST management strategy ? 

CONCLUSION
OCT in 2014  ESC guidelines

OCT is currently the best available imaging technique to explore stent thrombosis.

OCT allows us to better understand the pathophysiology of ST and discover new late stent failure mechanisms (neoatherosclerosis, evaginations..).

As OCT helps the physician to correctly identify the underlying stent mechanical  abnormalities, it also supports an adapted treatment strategy that could improve outcome.