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Multicenter Study
. 2017 Sep 12;136(11):1007-1021.
doi: 10.1161/CIRCULATIONAHA.117.026788. Epub 2017 Jul 18.

Optical Coherence Tomography Findings in Patients With Coronary Stent Thrombosis: A Report of the PRESTIGE Consortium (Prevention of Late Stent Thrombosis by an Interdisciplinary Global European Effort)

Tom Adriaenssens  1 , Michael Joner  1 , Thea C Godschalk  1 , Nikesh Malik  1 , Fernando Alfonso  1 , Erion Xhepa  1 , Dries De Cock  1 , Kenichi Komukai  1 , Tomohisa Tada  1 , Javier Cuesta  1 , Vasile Sirbu  1 , Laurent J Feldman  1 , Franz-Josef Neumann  1 , Alison H Goodall  1 , Ton Heestermans  1 , Ian Buysschaert  1 , Ota Hlinomaz  1 , Ann Belmans  1 , Walter Desmet  1 , Jurrien M Ten Berg  1 , Anthony H Gershlick  1 , Steffen Massberg  1 , Adnan Kastrati  1 , Giulio Guagliumi  1 , Robert A Byrne  2 ; Prevention of Late Stent Thrombosis by an Interdisciplinary Global European Effort (PRESTIGE) Investigators
Affiliations
Multicenter Study

Optical Coherence Tomography Findings in Patients With Coronary Stent Thrombosis: A Report of the PRESTIGE Consortium (Prevention of Late Stent Thrombosis by an Interdisciplinary Global European Effort)

Tom Adriaenssens et al. Circulation. .

Abstract

Background: Stent thrombosis (ST) is a serious complication following coronary stenting. Intravascular optical coherence tomography (OCT) may provide insights into mechanistic processes leading to ST. We performed a prospective, multicenter study to evaluate OCT findings in patients with ST.

Methods: Consecutive patients presenting with ST were prospectively enrolled in a registry by using a centralized telephone registration system. After angiographic confirmation of ST, OCT imaging of the culprit vessel was performed with frequency domain OCT. Clinical data were collected according to a standardized protocol. OCT acquisitions were analyzed at a core laboratory. Dominant and contributing findings were adjudicated by an imaging adjudication committee.

Results: Two hundred thirty-one patients presenting with ST underwent OCT imaging; 14 (6.1%) had image quality precluding further analysis. Of the remaining patients, 62 (28.6%) and 155 (71.4%) presented with early and late/very late ST, respectively. The underlying stent type was a new-generation drug-eluting stent in 50.3%. Mean reference vessel diameter was 2.9±0.6 mm and mean reference vessel area was 6.8±2.6 mm2. Stent underexpansion (stent expansion index <0.8) was observed in 44.4% of patients. The predicted average probability (95% confidence interval) that any frame had uncovered (or thrombus-covered) struts was 99.3% (96.1-99.9), 96.6% (92.4-98.5), 34.3% (15.0-60.7), and 9.6% (6.2-14.5) and malapposed struts was 21.8% (8.4-45.6), 8.5% (4.6-15.3), 6.7% (2.5-16.3), and 2.0% (1.2-3.3) for acute, subacute, late, and very late ST, respectively. The most common dominant finding adjudicated for acute ST was uncovered struts (66.7% of cases); for subacute ST, the most common dominant finding was uncovered struts (61.7%) and underexpansion (25.5%); for late ST, the most common dominant finding was uncovered struts (33.3%) and severe restenosis (19.1%); and for very late ST, the most common dominant finding was neoatherosclerosis (31.3%) and uncovered struts (20.2%). In patients presenting very late ST, uncovered stent struts were a common dominant finding in drug-eluting stents, and neoatherosclerosis was a common dominant finding in bare metal stents.

Conclusions: In patients with ST, uncovered and malapposed struts were frequently observed with the incidence of both decreasing with longer time intervals between stent implantation and presentation. The most frequent dominant observation varied according to time intervals from index stenting: uncovered struts and underexpansion in acute/subacute ST and neoatherosclerosis and uncovered struts in late/very late ST.

Keywords: atherosclerosis; malapposition; stents; thrombosis; tomography, optical coherence; uncovered struts.

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Figures

Figure 1.
Figure 1.
Optical coherence tomography findings in patients presenting with stent thrombosis classified according to time. A, Mean stent expansion index. B, Proportion of patients with at least 1 frame with uncovered struts. C, Proportion of patients with at least 1 frame with malapposed struts.
Figure 2.
Figure 2.
Representative images of optical coherence tomography findings in patients presenting with acute/subacute stent thrombosis. A, Edge dissection, with a dissection flap separating the true lumen (TL) from the false lumen (FL). B, Acute stent thrombosis with thrombus accumulation on uncovered stent struts. C, Multiple layers of overlapping struts in a segment with marked stent underexpansion and proximal area of thrombus (see also Figure 2E). D, Malapposed struts with thrombus accumulation. E, Corresponding longitudinal view of patient shown in Figure 2C with stent thrombosis in a very long stented segment with overlapping struts and marked stent underexpansion (C indicates the location of the cross section in Figure 2C). *Shadow artifact caused by guidewire.
Figure 3.
Figure 3.
Representative images of optical coherence tomography findings in patients presenting with late/very late stent thrombosis. A, Uncovered struts, with local accumulations of white thrombus (thr) (see also Figure 3E). B, Interstrut cavities (IC) with small thrombus deposition (thr). C, Severe restenosis with superimposed thrombus (thr). D, Neoatherosclerosis with lipid-rich plaque (L) and plaque rupture (indicated with red arrow). E, Corresponding longitudinal view of the patient with stent thrombosis and uncovered struts shown in Figure 3A. The length of the stented segment is indicated in blue. Thrombus is adherent to uncovered struts along the stented segment, visible as cauliflower-like structures protruding into the lumen (A indicates the location of the cross section in Figure 3A). SB indicates side branch. *Shadow artifact caused by guidewire.
Figure 4.
Figure 4.
Dominant findings identified by optical coherence tomography imaging according to time interval from index stenting to presentation.A, Acute stent thrombosis (<24 hours). B, Subacute stent thrombosis (24 hours to 30 days). C, Late stent thrombosis (>30 days to 1 year). D, Very late stent thrombosis (>1 year).
Figure 5.
Figure 5.
Dominant findings identified by optical coherence tomography imaging in very late stent thrombosis according to type of stent.BMS indicates bare metal stent; G1-DES, first-generation drug-eluting stent; and G2-DES, second-generation drug-eluting stent.
See this image and copyright information in PMC

Comment in

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