24: Early Stent Thrombosis

Published on 02/03/2015 by admin

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Last modified 02/03/2015

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CASE 24 Early Stent Thrombosis

Cardiac catheterization

A severe stenosis present in the proximal right coronary artery explained his symptoms (Figure 24-2 and Videos 24-1, 24-2). Atherosclerotic disease evident in the left coronary artery did not appear to cause significant luminal obstruction (Figures 24-3, 24-4). The operator proceeded with percutaneous intervention of the right coronary artery using a bolus and infusion of bivalirudin as the procedural anticoagulant. The patient received 325 mg of aspirin prior to catheterization and was dosed with 600 mg of clopidogrel at the start of the percutaneous coronary intervention. Using first a 2.5 mm diameter by 20 mm long compliant balloon to predilate the lesion, the operator then deployed a 3.0 mm diameter by 23 mm long sirolimus-eluting stent (Figure 24-5). Not satisfied with the angiographic result, the operator postdilated the stent with a 3.0 mm diameter noncompliant balloon to 18 atmospheres (Figure 24-6). This resulted in a satisfactory angiographic result (Figure 24-7 and Videos 24-3, 24-4) and the patient left the cardiac catheterization laboratory without chest pain. An electrocardiogram obtained approximately 1 hour after the procedure showed no changes compared to baseline (Figure 24-8).

Over the course of the afternoon, the patient reported continual low-grade chest discomfort, but repeat electrocardiograms showed no changes. Although the pain was attributed to noncardiac causes, it continued throughout the afternoon and failed to respond to nitrates, antacids, or positional changes. Approximately 6 hours after the intervention, the chest pain suddenly became acutely worse and was associated with diaphoresis, nausea, and bradycardia. An electrocardiogram obtained at this point revealed normalization of the previously present inferior T-wave changes and new ST-segment elevation in leads III and aVF (Figure 24-9). Emergency coronary angiography confirmed occlusion of the right coronary stent (Figure 24-10 and Video 24-5).

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