Sažetak
Uvod. Tromboza stenta (ST) može se klasifikovati u kliničkoj praksi, prema vremenu nastanka, u ranu (0–30 dana nakon implantacije stenta), koju možemo dalje podeliti na akutnu, ukoliko se javi u prva 24 h, subakutnu (1–30 dana), kasnu (> 30 dana) i veoma kasnu (> 12 meseci). Reinfarkt miokarda usled veoma kasne ST kod bolesnika na antiagregacionoj terapiji javlja se veoma retko i može biti smrtonosan. Proceduralni i tehnički faktori su povezani sa akutnom/subakutnom trombozom stenta. S druge strane, neoateroskleroza u području stenta, upala, prerano prekidanje antiagregacione terapije, kao i neadekvatna apozicija stenta igraju važnu ulogu u kasnoj/veoma kasnoj ST. Neka istraživanja pokazala su da je etiologija veoma kasne tromboze metalnog stenta (BMS) u značajnoj meri drugačija od one nakon implantacije stenta obloženog lekom (DES). Prikaz bolesnika. Prikazali smo 56-godišnjeg muškarca sa akutnim inferoposteriornim infarktom miokarda sa elevacijom ST segmenta (STEMI) usled veoma kasne tromboze stenta, 9 godina nakon implantacije BMS, uprkos primeni antiagregacione terapije. Učinjena je uspešna tromboaspiracija, nakon čega je urađena primarna perkutana koronarna intervencija (PKI) sa ugradnjom jednog DES na mestu prethodno implantiranih stentova i tako lečili in-stent restenozu. Zaključak. Veoma kasna tromboza stenta, iako srećom retka i još nedovoljno razjašnjena, može izazvati reinfarkt miokarda, ali se može uspešno lečiti tromboaspiracijom i primarnom PKI. Ruptura plaka neointime sa posledičnom trombozom može biti uzrok veoma kasne tromboze stenta kod prikazanog bolesnika.
Ključne reči
||stentovi
drug-eluting stents||
lekom obloženi
thrombosis||
||tromboza
myocardial infarction||
||infarkt miokarda
angioplasty
baloon||
||angioplastika
balonska
Reference
Kastrati A, Mehilli J, Pache J, Kaiser C, Valgimigli M, Kelbæk H, et al. Analysis of 14 Trials Comparing Sirolimus-Eluting Stents with Bare-Metal Stents. N Engl J Med 2007; 356(10): 1030−9.
Daemen J, Wenaweser P, Tsuchida K, Abrecht L, Vaina S, Morger C, et al. Early and late coronary stent thrombosis of sirolimus-eluting and paclitaxel-eluting stents in routine clinical practice: data from a large two-institutional cohort study. Lancet 2007; 369(9562): 667−78.
Kukreja N, Onuma Y, Garcia-Garcia HM, Daemen J, van Domburg R, Serruys PW. The Risk of Stent Thrombosis in Patients With Acute Coronary Syndromes Treated With Bare-Metal and Drug-Eluting Stents. JACC Cardiovasc Interv 2009; 2(6): 534−41.
King SB, Smith SC, Hirshfeld JW, Jacobs AK, Morrison DA, Williams DO, et al. 2007 focused update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice guidelines. J Am Coll Cardiol 2008; 51(2): 172−209.
Lagerqvist B, James SK, Stenestrand U, Lindbäck J, Nilsson T, Wal-lentin L. Long-Term Outcomes with Drug-Eluting Stents ver-sus Bare-Metal Stents in Sweden. N Engl J Med 2007; 356(10): 1009−19.
Parodi G, Marcucci R, Valenti R, Gori AM, Migliorini A, Giusti B, et al. High residual platelet reactivity after clopidogrel loading and long-term cardiovascular events among patients with acute coronary syndromes undergoing PCI. JAMA 2011; 306(11): 1215−23.
Luscher TF, Steffel J, Eberli FR, Joner M, Nakazawa G, Tanner FC, et al. Drug-Eluting Stent and Coronary Thrombosis: Biological Mechanisms and Clinical Implications. Circulation 2007; 115(8): 1051−8.
Joner M, Finn AV, Farb A, Mont EK, Kolodgie FD, Ladich E, et al. Pathology of drug-eluting stents in humans: delayed healing and late thrombotic risk. J Am Coll Cardiol 2006; 48(1): 193−202.
Nakazawa G, Otsuka F, Nakano M, Vorpahl M, Yazdani SK, La-dich E, et al. The pathology of neoatherosclerosis in human coronary implants bare-metal and drug-eluting stents. J Am Coll Cardiol 2011; 57(11): 1314−22.
Doyle B, Rihal CS, O'Sullivan CJ, Lennon RJ, Wiste HJ, Bell M, et al. Outcomes of stent thrombosis and restenosis during ex-tended follow-up of patients treated with bare-metal coronary stents. Circulation 2007; 116(21): 2391−8.
Bangalore S, Kumar S, Fusaro M, Amoroso N, Attubato MJ, Feit F, et al. Short- and long-term outcomes with drug-eluting and bare-metal coronary stents: a mixed-treatment comparison analysis of 117 762 patient-years of follow-up from rando-mized trials. Circulation 2012; 125(23): 2873−91.
O'Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, et al. American College of Cardiology Founda-tion/American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the Ameri-can College of Cardiology Foundation/American Heart Asso-ciation Task Force on Practice Guidelines. Circulation 2013; 127(4): e362−425.
Burzotta F, Parma A, Pristipino C, Manzoli A, Belloni F, Sardella G, et al. Angiographic and clinical outcome of invasively managed patients with thrombosed coronary bare metal or drug-eluting stents: the OPTIMIST study. Eur Heart J 2008; 29(24): 3011−21.
Mauri L, Hsieh W, Massaro JM, Ho KK, D'Agostino R, Cutlip DE. Stent thrombosis in randomized clinical trials of drug-eluting stents. N Engl J Med 2007; 356(10): 1020−9.
Kirtane AJ, Gupta A, Iyengar S, Moses JW, Leon MB, Applegate R, et al. Safety and efficacy of drug-eluting and bare metal stents: comprehensive meta-analysis of randomized trials and obser-vational studies. Circulation 2009; 119(25): 3198−206.
Cannon CP, Harrington RA, James S, Ardissino D, Becker RC, Emanuelsson H, et al. Comparison of ticagrelor with clopidogrel in patients with a planned invasive strategy for acute coronary syndromes (PLATO): a randomised double-blind study. Lan-cet 2010; 375(9711): 283−93.
Montalescot G, Wiviott SD, Braunwald E, Murphy SA, Gibson C, McCabe CH, et al. Prasugrel compared with clopidogrel in pa-tients undergoing percutaneous coronary intervention for ST-elevation myocardial infarction (TRITON-TIMI 38): double-blind, randomised controlled trial. Lancet 2009; 373(9665): 723−31.