Bivalirudin as rescue therapy for suspected heparin resistance and recurrent intra-procedural stent thrombosis during complex percutaneous coronary intervention: a case report

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Suspected heparin resistance and recurrent intra-procedural stent thrombosis during complex percutaneous coronary intervention (n=1). Intervention: Bivalirudin vs. Unfractionated heparin. Primary outcome: Achievement of therapeutic anticoagulation (ACT) and thrombus resolution.

Q: What does this research mean for the field?

Switching to the direct thrombin inhibitor bivalirudin rapidly achieves therapeutic anticoagulation and reduces thrombus burden in patients with heparin resistance and recurrent intra-procedural stent thrombosis during complex percutaneous coronary intervention. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Xiang Wang; Miao Dai

doi:10.3389/fcvm.2026.1864489

July 9, 2026Frontiers in Cardiovascular MedicineOpen Access

Bivalirudin as rescue therapy for suspected heparin resistance and recurrent intra-procedural stent thrombosis during complex percutaneous coronary intervention: a case report

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Key result

Bivalirudin overcomes suspected heparin resistance during complex PCI, achieving therapeutic anticoagulation within ~10 minutes.

n=1

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Why the study?

Heparin resistance poses a significant challenge during PCI that can potentially lead to catastrophic thrombotic complications.

Does bivalirudin improve anticoagulation and resolve thrombosis in a patient with suspected heparin resistance during complex PCI?

Key Points

To describe the rescue use of bivalirudin in managing suspected refractory heparin resistance and recurrent acute intra-stent thrombosis during complex percutaneous coronary intervention.
Case report evaluating a patient with a heavily calcified coronary lesion undergoing complex percutaneous coronary intervention who developed recurrent intra-stent thrombosis.
Anticoagulation was initially attempted with escalating boluses of unfractionated heparin and adjunctive antiplatelet therapies, followed by transition to intravenous bivalirudin (0.75 mg/kg bolus and 1.75 mg/kg/h infusion).
Unfractionated heparin failed to achieve therapeutic anticoagulation despite repeated boluses up to a cumulative dose of 11,000 U (153 U/kg), maintaining a subtherapeutic activated clotting time of 132 s.
Switching to bivalirudin achieved therapeutic anticoagulation with an activated clotting time of 320 s within 10 min.
Angiography confirmed substantial thrombus reduction following bivalirudin, mechanical post-dilation, and thrombectomy, with 4-month follow-up showing a patent stent, no thrombus, and TIMI grade 3 flow.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

Does bivalirudin improve anticoagulation and resolve thrombosis in a patient with suspected heparin resistance during complex PCI?

P

Population

A 67-year-old male undergoing complex percutaneous coronary intervention who developed suspected heparin resistance and recurrent intra-stent thrombosis.

I

Intervention

Bivalirudin (0.75 mg/kg intravenous bolus followed by 1.75 mg/kg/h infusion) as rescue therapy.

O

Outcome

Achievement of therapeutic anticoagulation (activated clotting time [ACT]) and reduction in thrombus burden.

Bivalirudin serves as an effective rescue strategy for managing suspected heparin resistance and preventing thrombosis progression during complex PCI.

Limitations

Lack of antithrombin III and anti-Xa level measurement during the emergency procedure to definitively confirm true heparin resistance.
Thrombus resolution was multifactorial, involving mechanical post-dilation, thrombectomy, and intracoronary thrombolytic/antiplatelet therapy, limiting causal attribution solely to bivalirudin.
Causality of thrombus resolution cannot be attributed solely to the switch in anticoagulant strategy due to concurrent mechanical and pharmacologic interventions.

Implication

Bivalirudin may resolve anticoagulation failure in heparin-resistant PCI; leaves open need for prospective validation before broader adoption.

Abstract

Heparin resistance (HR) poses a significant challenge during percutaneous coronary intervention (PCI), potentially leading to catastrophic thrombotic complications. Here, we report a case of suspected refractory HR and recurrent intra-stent thrombosis during a complex PCI for a heavily calcified lesion, despite aggressive antiplatelet therapy and glycoprotein IIb/IIIa inhibition. Subtherapeutic anticoagulation persisted despite repeated unfractionated heparin boluses [cumulative dose 11,000 U; activated clotting time (ACT) 132 s]. Switching anticoagulation to the direct thrombin inhibitor bivalirudin resulted in rapid achievement of therapeutic anticoagulation (ACT 320 s within 10 min) and marked reduction in thrombus burden. This case highlights bivalirudin as an effective rescue strategy for managing HR and preventing thrombosis progression in complex PCI settings, emphasizing the need for timely recognition and alternative anticoagulation in such high-risk scenarios.

Discussion

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Cite This Study

Wang et al. (2026) conducted a case report in Suspected heparin resistance and recurrent intra-procedural stent thrombosis during complex percutaneous coronary intervention (n=1). Bivalirudin vs. Unfractionated heparin was evaluated on Achievement of therapeutic anticoagulation (ACT) and thrombus resolution. Switching to bivalirudin rapidly achieved therapeutic anticoagulation (ACT 320 s within 10 min) and reduced thrombus burden in a patient with suspected heparin resistance during complex PCI.

synapsesocial.com/papers/6a704c4d26a7f98052dccd3f https://doi.org/10.3389/fcvm.2026.1864489

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Bivalirudin as rescue therapy for suspected heparin resistance and recurrent intra-procedural stent thrombosis during complex percutaneous coronary intervention: a case report

Figures

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

Bivalirudin as rescue therapy for suspected heparin resistance and recurrent intra-procedural stent thrombosis during complex percutaneous coronary intervention: a case report

Figures

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

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