Long-Term Outcomes and Clinical Predictors of Mortality Following Occurrence of Stent Thrombosis

Abstract

Background Stent thrombosis (ST) remains a significant medical issue. In particular, longer-term mortality and clinical predictors after ST occurrence have yet to be elucidated. Methods and Results This was a multicenter, retrospective, observational study. A total of 187 definite ST cases from January 2008 to December 2017 were enrolled, and the long-term clinical outcomes were investigated. The primary outcome measure was the cumulative mortality after ST occurrence. In addition, independent predictors of mortality were assessed. Among the stent types causing ST, bare-metal stent, first-generation drug-eluting stent, second-generation drug-eluting stent, and third-generation drug-eluting stent comprised 31.0%, 19.3%, 36.9%, and 6.4% of cases, respectively. Median duration from stent implantation to ST was 680.5 (interquartile range, 33.8-2450.5) days. Cumulative mortality was 14.6%, 17.4%, 21.2%, 24.4%, and 33.8% at 1, 2, 3, 5 and 10 years, respectively. The cumulative mortality did not significantly differ by type of stent, and mortality of late ST was higher than that of early ST and very late ST; however, it did not reach statistical significance after the multivariate analysis. Independent predictors of mortality were hemodialysis (hazard ratio [HR], 7.80; 95% CI, 3.07-19.81; P<0.001), culprit lesions in the left main trunk (HR, 8.14; 95% CI, 1.71-38.75; P=0.008), culprit lesions in the left coronary artery (HR, 2.77; 95% CI, 1.10-6.96; P=0.030), and peak creatine kinase (HR, 1.017; 95% CI, 1.011-1.022; P<0.001). Conclusions The 10-year cumulative mortality after ST reached 33.8%. Close follow-up is thus mandatory for patients with ST, especially with hemodialysis, culprit lesions in the left main trunk and left coronary artery, and high peak creatine kinase.

Keywords: long‐term outcomes; mortality; stent thrombosis.

Figure 1. Study flowchart.

A total of 187 cases with ST from January 2008 to December 2017 were enrolled in this registry. Quantitative coronary angiography analysis was possible for 76 patients and 156 patients at the time of initial PCI and ST, respectively. Pre‐ and post‐PCI intravascular ultrasound analyses at the time of ST were available for 67 patients and 71 patients, respectively. IVUS indicates intravascular ultrasound; PCI, percutaneous coronary intervention; QCA, quantitative coronary angiography; and ST, stent thrombosis.

Figure 2. Cumulative mortality after the occurrence of stent thrombosis.

The cumulative incidence of all‐cause death was 14.6%, 17.4%, 21.2%, 24.4%, and 33.8% at 1, 2, 3, 5, and 10 years, respectively.

Figure 3. Cumulative mortality by type of stent and ST.

A, Cumulative mortality by type of stent. Although cumulative mortality tended to be higher among patients with third‐generation DES, differences among the stent types did not reach statistical significance after Bonferroni correction. B, Cumulative mortality by type of ST. Mortality of late ST was higher than that of early ST and very late ST. BMS indicates bare‐metal stent; DES, drug‐eluting stent; and ST, stent thrombosis.

Figure 4. Cumulative incidence of secondary outcomes.

A, Cumulative incidence of major adverse cardiac events. The cumulative incidence was 23.9%, 30.0%, 36.7%, 39.2%, and 41.9% at 1, 2, 3, 5, and 10 years, respectively. B, Cumulative incidence of cardiac death. The cumulative incidence was 9.4%, 11.5%, 13.2%, and 14.7% at 1, 2, 3, and 5 years, respectively. No events occurred after 5 years. C, Cumulative incidence of nonfatal myocardial infarction. The cumulative incidence was 3.6%, 4.4%, and 7.3% at 1, 2, and 3 years, respectively. No events occurred after 3 years. D, Cumulative incidence of target lesion revascularization. The cumulative incidence was 16.4%, 20.9%, 26.6%, 27.8%, and 31.0% at 1, 2, 3, 5, and 10 years, respectively. E, Cumulative incidence of target vessel revascularization. The cumulative incidence was 18.3%, 25.1%, 30.8%, 32.0%, and 35.1% at 1, 2, 3, 5, and 10 years, respectively. F, Cumulative incidence of recurrent stent thrombosis. The cumulative incidence was 4.9%, 5.7%, and 7.5% at 1, 2, and 3 years, respectively. No events occurred after 3 years.

Figure 5. Visual overview.

The 10‐year cumulative mortality after stent thrombosis was 33.8%. The independent predictors for all‐cause death were hemodialysis, culprit lesions in left main trunk and left coronary artery, and peak creatine kinase. The 10‐year incidence of major adverse cardiac event (MACE), cardiac death, nonfatal myocardial infarction, target lesion revascularization (TLR), target vessel revascularization, and recurrent stent thrombosis was 41.9%, 14.7%, 7.3%, 31.0%, 35.1%, and 7.5%. Quantitative coronary angiography analysis suggested that post‐PCI in‐segment diameter stenosis was higher in patients with than without MACE, while intravascular ultrasound findings implied that stent underexpansion before and immediately after PCI at the time of stent thrombosis was more frequently observed in patients with than without TLR. HR indicates hazard ratio; OCVC, Osaka CardioVascular Conference; and PCI, percutaneous coronary intervention.