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(Circulation. 2008;118:1117-1119.)
© 2008 American Heart Association, Inc.

Editorial

Late Stent Thrombosis After Drug-Eluting Stent Implantation for Acute Myocardial Infarction

A New Red Flag Is Raised

Matthias E. Pfisterer, MD

From the Department of Cardiology, University Hospital, Basel, Switzerland.

Correspondence to Matthias Pfisterer, MD, FACC, FAHA, FESC, Professor of Cardiology, Head Department of Cardiology, University Hospital, CH-4031 Basel, Switzerland. E-mail pfisterer@email.ch

Key Words: Editorials • angioplasty • coronary disease • myocardial infarction • stents • thrombosis

An extract of the first 250 words of the full text is provided, because this article has no abstract.

	Introduction

 
Late stent thrombosis (ST) made headlines when investigators realized that clinical events related to late ST, although rare, carried a mortality rate of up to 45% and a nonfatal infarction rate of another 30% to 40%.^1,2 These rates clearly were more than those seen after bare metal stent (BMS) implantation, as first shown prospectively in the randomized Basel Stent Kosten Effektivitäts Trial–Late Thrombotic Events (BASKET-LATE).² This led to a "firestorm," which cooled off in view of the facts that these rare events are counterbalanced to some extent by fewer restenosis-related events in patients treated with drug-eluting stents (DES) versus BMS^2,3 and that results of meta-analyses of earlier randomized trials⁴ and findings of large registries showed no overall excess mortality after DES versus BMS. Still, after DES implantation, late ST does occur, later than after BMS, at a relatively constant rate over time up to at least 4 years after stenting⁵ and, unlike after BMS, appears as primary thrombosis with a sudden unexpected clinical event not related to repeat interventions. Autopsy studies showed that delayed healing, ie, the lack of incomplete endothelial coverage of stent struts associated with persistence of fibrin deposits, is the primary pathoanatomic substrate of late ST after DES implantation.⁶ This was not found in patients with BMS. Delayed healing is the mechanism for late ST, ie, ST after 30 days of stent implantation, which was confirmed by intravascular ultrasound⁷ and angioscopic studies,⁸ and is quite different from early ST. Here, procedural factors such as incomplete lesion coverage, . . . [Full Text of this Article]