Key result
Triple therapy fails to prevent subacute LAD stent thrombosis, dropping LVEF to ~25%.
Why the study?
Recurrent stent thrombosis across multiple coronary territories in the same patient is exceptional and raises questions about predisposing factors and antithrombotic strategy, especially in patients with AF requiring oral anticoagulation.
Case Report (n=1)
No
This case demonstrates that maximal antithrombotic protection with triple therapy (aspirin, clopidogrel, rivaroxaban) does not completely eliminate the risk of early recurrent stent thrombosis, highlighting the need for intravascular imaging, platelet function testing, and thrombophilia screening in such cases.
Stent thrombosis risk persists on triple therapy post-PCI in AF; case reports leave open optimal regimens for this population.
Introduction: Stent thrombosis is a rare but serious complication of percutaneous coronary intervention (PCI), with high morbidity and mortality. Recurrence in several coronary territories in the same patient is exceptional and raises questions about predisposing factors and antithrombotic strategy, especially in patients with atrial fibrillation (AF) who require oral anticoagulation. Case presentation: We report the case of a 69-year-old man with known coronary artery disease (right coronary artery stent in 2016), former smoker and cannabis user, with dyslipidaemia and paroxysmal AF on rivaroxaban. Eight weeks before admission, he had an inferobasal myocardial infarction due to thrombotic occlusion of the right coronary artery at the site of the old stent (very late stent thrombosis), complicated by an electrical storm and treated with stent-in-stent implantation. Ten days before admission, a drug-eluting stent was implanted in the mid left anterior descending artery (LAD). He was admitted for an extensive anterior ST segment elevation myocardial infarction while on triple antithrombotic therapy (aspirin, clopidogrel, rivaroxaban), with no reported interruption. Coronary angiography showed thrombotic in-stent occlusion of the mid LAD (TIMI 0 flow), treated with balloon angioplasty and intracoronary tenecteplase, with final TIMI 2 flow. The course was complicated by left ventricular failure (ejection fraction falling from 51% to 25%) and right-sided pneumonia. Because of a suspected apical thrombus, rivaroxaban was replaced by acenocoumarol, and he was discharged on one month of triple antithrombotic therapy (aspirin, clopidogrel, acenocoumarol) and full heart failure therapy. Conclusion: This case illustrates the multifactorial nature of stent thrombosis: maximal antithrombotic protection (triple therapy) does not eliminate the risk. Recurrent stent thrombosis despite well-conducted treatment should prompt intravascular imaging to identify mechanical causes, consideration of poor response to antiplatelet agents and thrombophilia, and adjustment of antithrombotic intensity.
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Ely et al. (2026) conducted a case report in Recurrent stent thrombosis and atrial fibrillation (n=1). Triple antithrombotic therapy (aspirin, clopidogrel, rivaroxaban/acenocoumarol) and emergency PCI with balloon angioplasty and intracoronary tenecteplase was evaluated on Clinical and angiographic outcome following recurrent stent thrombosis (TIMI flow and LVEF). Triple antithrombotic therapy (aspirin, clopidogrel, rivaroxaban) failed to prevent subacute LAD stent thrombosis at day 10 post-PCI, which lowered LVEF from 51% to 25% despite TIMI 2 recanalisation.
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