Association of Localized Hypersensitivity and In-Stent Neoatherosclerosis with the Very Late Drug-Eluting Stent Thrombosis

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Drug-eluting stent thrombosis (n=48). Intervention: Very late stent thrombosis (>1 year) vs. Early (≤30 days) and late (31-365 days) stent thrombosis. Primary outcome: Eosinophil fraction in the aspirated thrombi (p=0.03).

Kyohei Yamaji; Shunsuke Kubo; Katsumi Inoue; Kazushige Kadota; Shoichi Kuramitsu; Shinichi Shirai; Kenji Andò; Masakiyo Nobuyoshi; Kazuaki Mitsudo; Takeshi Kimura

doi:10.1371/journal.pone.0113870

November 25, 2014PLoS ONEOpen Access

Association of Localized Hypersensitivity and In-Stent Neoatherosclerosis with the Very Late Drug-Eluting Stent Thrombosis

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Key result

Very late drug-eluting stent thrombosis was associated with a significantly higher eosinophil fraction in aspirated thrombi (8.2%) compared to early (4.3%) and late (5.5%) stent thrombosis.

Why the study?

Is very late drug-eluting stent thrombosis associated with higher eosinophil fractions in aspirated thrombi compared to early or late stent thrombosis?

Study Design

Type

Observational (n=48)

Blinding

Single-blind

Multicenter

Yes

Structured PICO

Is very late drug-eluting stent thrombosis associated with higher eosinophil fractions in aspirated thrombi compared to early or late stent thrombosis?

P

Population

48 patients (mean age 67, 17% female) with definite drug-eluting stent thrombosis who underwent thrombus aspiration with sufficient material for histopathologic analysis.

E

Exposure

Very late stent thrombosis (VLST, >1 year)

C

Comparator

Early stent thrombosis (EST, within 30 days) and late stent thrombosis (LST, between 31 and 365 days)

O

Outcome

Eosinophil fraction in the aspirated thrombisurrogate

Main Result

p-value: p=0.03

Very late drug-eluting stent thrombosis is associated with a higher eosinophil fraction in aspirated thrombi, suggesting localized hypersensitivity as a potential underlying mechanism, while evidence of neoatherosclerosis was relatively uncommon.

Limitations

Small sample size limits the ability to fully elucidate the prevalence of inflammatory cell infiltrates and atherosclerosis.
Uncertainty whether eosinophils in the aspirated thrombi were actually derived from the stented vessel wall.
Thrombus aspiration may not fully retrieve components of the arterial wall, meaning absence of plaque fragments does not rule out neoatherosclerosis.
All very late stent thrombosis cases involved first-generation drug-eluting stents, limiting generalizability to newer generation stents.
Intravascular ultrasound was not performed for all patients, and optical coherence tomography was not used.
High proportion of patients underwent index DES deployment for restenotic lesions, which could be associated with late changes around the stent struts.

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

May implicate hypersensitivity in very late DES thrombosis; hypothesis-generating and should not change practice.

Abstract

BACKGROUND: Localized hypersensitivity reaction, delayed arterial healing, and neoatherosclerosis inside the stent have been suggested as the underlying pathologic mechanisms of very late stent thrombosis (VLST) of drug-eluting stent (DES). The present study sought to explore the prevalence of inflammatory cell infiltrates and evidence for fragments of atherosclerotic plaques in the aspirated thrombi in patients with DES VLST. METHODS AND RESULTS: From April 2004 to September 2012, 48 patients with stent thrombosis (ST) of DES underwent thrombus aspiration with retrieved material sufficient for the histopathologic analysis; early ST (EST, within 30 days): N = 17, late ST (LST, between 31 and 365 days): N = 7, and very late ST (VLST, >1 year): N = 24. Eosinophil fraction in the aspirated thrombi was significantly higher in patients with VLST (8.2±5.7%) as compared with those with EST (4.3±3.0%) and LST (5.5±3.8%) (P = 0.03). Eosinophil fraction in the aspirated thrombi was significantly higher in 12 VLST patients with angiographic peri-stent contrast staining (PSS) and/or incomplete stent apposition (ISA) by intravascular ultrasound than in 12 VLST patients without PSS or ISA (10.6±6.1% versus 5.8±4.1%, P = 0.03). Evidences for fragments of atherosclerotic plaques in the aspirated thrombi were observed only in 3 (13%) out of 24 patients with DES VLST. CONCLUSIONS: Eosinophil fraction in the aspirated thrombi was significantly higher in patients with DES VLST as compared with those with EST and LST. Evidences for fragments of atherosclerotic plaques were relatively uncommon in patients with DES VLST.

Discussion

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Cite This Study

Yamaji et al. (2014) conducted an observational in Drug-eluting stent thrombosis (n=48). Very late stent thrombosis (>1 year) vs. Early (≤30 days) and late (31-365 days) stent thrombosis was evaluated on Eosinophil fraction in the aspirated thrombi (p=0.03). Very late drug-eluting stent thrombosis was associated with a significantly higher eosinophil fraction in aspirated thrombi (8.2%) compared to early (4.3%) and late (5.5%) stent thrombosis.

synapsesocial.com/papers/6a843eafd7bfb55d357305e3 https://doi.org/10.1371/journal.pone.0113870

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Association of Localized Hypersensitivity and In-Stent Neoatherosclerosis with the Very Late Drug-Eluting Stent Thrombosis

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Association of Localized Hypersensitivity and In-Stent Neoatherosclerosis with the Very Late Drug-Eluting Stent Thrombosis

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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