Very Late Bare Metal Stent Thrombosis

Very late stent thrombosis is a rare and not-well-understood complication after bare metal stent implantation. It usually presents as an ST elevation acute coronary syndrome and it is associated with high rates of morbidity and mortality. Pathophysiologic mechanisms are not well defined; nevertheless, recent studies have proposed a neoatherosclerotic process as the triggering mechanism. We present the case of a patient with bare metal very late stent thrombosis 12 years after implantation. 1. Case Presentation In 2000, a 66-year-old man was admitted to the emergency department (ED) for acute retrosternal chest pain, intensity 10/10, irradiated to neck and associated with dyspnea and diaphoresis; within the last week he had had similar episodes. Patient was an active smoker. In the ED an electrocardiogram was performed, showing acute changes suggesting anterior wall myocardial infarction. Thrombolytic therapy with streptokinase was used and the patient was derived to the catheterization laboratory. Coronary angiography revealed subtotal occlusion of the proximal and middle left anterior descending coronary artery (LDA), balloon angioplasty with a ？mm balloon was performed at 8？atm, and two bare metal stents were implanted: ML ？mm and ML ？mm respectively, with excellent angiographic results. Patient was discharged with aspirin, warfarin, diuretics, and ACE inhibitor. In September 2012 patient was admitted to the ED for intermittent acute chest pain. Twelve lead electrocardiogram evidenced anterior ST segment elevation. After administration of aspirin 300？mg and ticagrelor 180？mg, patient was driven to the catheterization laboratory. Coronary angiography revealed total thrombotic occlusion of the previous stented segment of the LDA with an abrupt cutoff of septal and diagonal branches (Figure 1). Predilatation with a Splinter balloon ？mm was performed at 18？atm and stent Endeavour Resolute Integrity ？m was implanted at 18？atm, restoring perfusion to distal TIMI 3 flow (Figure 2). Patient had an adequate clinical course and was discharged with dual antiplatelet treatment with aspirin and ticagrelor, beta blocker, and statin. Figure 1: Total thrombotic occlusion of the previously stented segment of the LDA. LDA: left descending artery. Figure 2: Restoration of perfusion of？？LDA to distal TIMI 3 flow. 2. Discussion Coronary percutaneous intervention with stenting is one of the most widely performed procedures for the treatment of symptomatic coronary artery disease. Even though drug eluting stents have diminished bare metal stent limitations, there remain