PCI: devil or angel? Repeated Stent Thrombosis after

Emergency PCIYu-Jie Zhou | MD, PhD Linlin Zhang | MD Beijing

Anzhen Hospital

Basic Information

• Mr. Wang Male 56y • Risk Factors Hypertension 10y Diabetes Mellitus

5y Smoking 20y

• Admitted in local hospital with “sudden serious chest pain”

Event Records2013.3 1st AMI AMI(Inferior,

Posterior)1st PCI PCI(RCA)

1 week later

CAG LAD: Proximal-mid 60-85%RCA: Distal 100% Thrombosis in stent

2nd PCI

Selected PCI(LAD)+Repeated PCI(RCA)

1 hour after PCI

2nd AMI

AMI(Inferior, Posterior, extensive Anterior )

3rd PCI PTCA(LAD)

Tirofiban reduction

3rd AMI

AMI(Anterior )

Tirofiban reduction

4th AMI AMI(Extensive anterior )

11stst AMI(Inferior, Posterior) 11stst PCI

23/4/20

CAG: Distal-RCA occlusion

PCI:2.75*18mm stent in RCA

22ndnd PCI( PCI(Selected PCI)

23/4/20

CAG: 60-85% in Proximal-mid LAD

PCI: 2.75*33mm,3.0*28mm in LAD

23/4/20

CAG: occlusion in a previously implanted stent in RCA

PCI:2.5*24mm stent in RCA connected with previous stent

22ndnd PCI( PCI(Selected PCI)

22ndnd AMI(Inferior, Anterior ) 33rdrd PCI

23/4/20

CAG: Occlusion in a previously implanted stent in RCA & LAD

23/4/20

22ndnd AMI(Inferior, Anterior ) 33rdrd PCI

PTCA with LAD

Antithrombotic Therapy

1st AMI1st PCI

Regular treatment(Clopidogrel 600mg)

2nd PCI Aspirin + Clopidogrel + Tirofiban(7ml/h) + LMWH

2nd AMI Tirofiban was adjusted to 14ml/h

3rd PCI

Injection from catheter: Tirofiban 20ml*2 UK 250,000uAspirin + Clopidogrel (150mgQD)+ Tirofiban(14ml/h) + Heparin

3rd AMI Aspirin(300mgBid) + Clopidogrel (150mgQD)+ Cilostazol (100mg Bid) Tirofiban(7ml/h) + Heparin

4th AMI Ditto

Clinical Reception

• Coronary Artery Disease Repeated AMI (Inferior, Posterior, extensive anterior ) Repeated Stent Thrombosis Pump Failure

• Hypertension• Diabetes Mellitus

First Sight with Patient Condition in ANZHEN Hospital

23/4/20

感染： WBC 18.18G/L ；中性 90.9% ；贫血： HGB107g/l ；血小板减低： PLT 43.0G/L ；急性心肌梗死： TnI 12.12ng/ml ；肾功能不全： Cr 140umol/L ； BUN 13.9mmol/L ；低蛋白血症：白蛋白 22.7g/L ；心功能衰竭： UCG ：节段性室壁运动异常，左室舒张功能减低， EF25% ，室壁瘤形成（ 50*38mm ），巨大血栓（ 42*38mm ）； ECG ：肢导低电压， V1-V5 导联呈 QS

型

23/4/20

Antithrombotic Strategy

Probability of Revascularization

Stent Thrombosis is Multifactorial

Lesion

• Long lesion• Small diameter• Multivessel• AMI• Diabetics• Bifurcations

Technical

• Underexpansion• Incomplete wall

apposition• Crush technique

• Drug compliance• Plavix withdrawal• Drug Resistance

• Design• Material

composition• Coating integrity• Drug/Agents

specific risks• Antithrombotic

treatments

Patient

Stent

Deterioration in patient

• Chest congestion

• Pink bubble sputum cough

• Dyspnea• Hyoxemia

• Drop of blood

pressure• Coma

• Acute pulmonary

edema• Acute left heart

failure• Acute respiratory

failure• Acute

cardiogenic shock

23/4/20

23/4/20

IABPIABP

ECMOECMO VentilatorVentilatorSIMV+Pressure SurportRR 8/min PEEP 6 FiO 40% Inspiration Pressure 4 Mve

3.6L

Heart rate tracking 1 ：1

4044rev 3.5L/min

DiuresisSodium nitroprusside Dopamine

Therapeutic process3rd Day IABP4th Day Pump failure, Renal Failure, Respiratory Failure5th Day ECMO, Breathing machine

Antithrombotic strategyAspirin(100mgQd) + Ticagrelor(90mgBid)+ Tirofiban(5-2ml/h) + LMWHWait for an opportunity with

revascularization10th Day CAG+PTCA(ECMO+IABP)

23/4/20

PCI Up-to-dateUp-to-date CAG: Recurrence Occlusion in a previously

implanted stent Same as second AMI

PCI Up-to-dateUp-to-date PTCA with LAD & RCA

LAD: Tirofiban 10ml RCA: Tirofiban 6ml Thrombus aspiration: PCAB 3060

23/4/20

Discussion

23/4/20

2011 ACCF/AHA/SCAI Guideline for PCI

Levine et al. Circulation 2011.

Cardiogenic Shock: Recommendations

Developed with the special contribution of the European Association for Percutaneous Cardiovascular Interventions (EAPCI) et al. Eur Heart J 2010;31:2501-2555

Treatment algorithms for acute heart failure and cardiogenic shock.

23/4/20

PROs CONs

IABP Improve Cardiac Output

Reduce afterload

Increase Coronary Perfusion

Ease of Use

Lower Complication rate over time

Does not unload the heart

Require a minimum of cardiac

function

Require a stable rhythm

No proven benefit on mortality

ECMO ECMO provides a temporary support in

order to perform an invasive cardiac

treatment (CABG or PCI), or to wait for

heart transplant

limited duration of 7 to 10 days, in

particular due to hemorrhagic &

hemolytic complications

23/4/20

The US Department of Justice (DoJ) is investigating

AstraZeneca's PLATO trial of ticagrelor (Brilinta)October 31, 2013

Apparent Geographic Discrepancies in the trial- A trend toward worse outcomes at North American sites(1814 patients in the US and Canada, a primary end point occurring in 11.9% of ticagrelor-treated patients compared with 9.6% of those on clopidogrel, although the difference was not significant)

23/4/20

Ticagrelor Bests Clopidogrel for Reducing Stent-Thrombosis Risk: PLATO

Published online July 30, 2013 in Circulation.

"In the present subgroup analysis of the PLATO trial in patients with coronary

stents, ticagrelor compared with clopidogrel reduced the incidence of stent

thrombosis, regardless of the definition used"

Ticagrelor Clopidogrel

Definite stent thrombosis 1.37% 1.93% 33%

Definite or probable stent thrombosis

2.21% 2.87% 25%

23/4/20

Ticagrelor More Cardioprotective Than Clopidogrel

December 31, 2012 online paper in Circulation

At up to one year of follow-up, primary outcome events -- cardiovascular death, myocardial infarction, and stroke - had occurred in 1,057 ticagrelor patients and 1,225 clopidogrel patients (rate ratio=0.86, p=0.003)

Stronger antiplatelet agent ticagrelor did a better job than clopidogrel (Plavix) in

preventing not only the first heart attack, but also second or third ones -- including

fatal ones."

Take Home Message

• Revascularization is still the key point for patient’s recovery

• PCI is the weapon, knowing how to use it is the only way we win the war with the

disease

• IABP and ECMO are good assistant devices for doctors. Don’t hesitate to

use them when necessary• Individual antithrombotic strategy for

your patients