Sunday, March 25, 2007


Much has been written about this new, revolutionary treatment of Coronary artery disease. When the first clinical trial was reported in 2001, almost all the leaders in this field of interventional cardiology hailed this new "drug-eluting stent " as a revolutionary treatment of CAD, in view of the fact that the "First in Man " experience with the sirolimus eluting stent, showed "zero"restenosis at 12 months. I remember attending that meeting and many of us were saying that only God gives zero restenosis. Little did we know at that time that near zero restenosis comes packaged with a new disease of stent thrombosis, in particular late-stent thrombosis, or even very late-stent thrombosis. Yes we do see stent thrombosis in bare metal stents, but I remember that that usually occurred in the initial 30 days following stent implantation. I remembered a 70 year old priest who received one of the first Palmaz-Schatz stents ( bare metal ) ho developed subacute stent thrombosis on reaching home after discharge. He duely returned to emergency room. I diagnose the stent thrombosis ( we called it subacute stent thrombosis ), took him to the angio room and open the thrombosed stent with plain old balloon angioplasty. With bare-metal stents, there was a time-window when this may occur. With DES, one of the problems is that the late stent thrombosis may occur months or years after the implantation, causing some to write dramaticlly that we have implanted time bombs in our patient. So sensational? I remember another Chinese gemtleman who had late-stent thrombosis, 18 months after the DES implantation. But we are also learning that even bare metal stents may have late stent thrombosis. Just last week, I did a patient ( 56yrs Ch male ) who had acute chest pains from an inferior MI. He had a bare metal stent implanted in his RCA about 4 years ago, and was on longterm ticlopidine. 3 weeks prior, he had GIT bleed aand the ticlopidine was stopped. One week later, he had the inferior MI. The angiogram showed that the mid-portion of my RCA stent was thrombosed. When I wire across the thrombus, the Guidewire exited the stent and re-entered again, telling me that portions of the bare metal stent was not endothelialised after 4 years. ( This is all on film ). So bare metal stents also have this problem of very late stent thrombosis, but perhaaps, it was uncommon, and not much data was kept of them. Perhaps what all this hooha about "the dangers of DES " taught me was that we should show more respect in using DES. We should be more choosy, and give a second thought before pulling out the DES. ( At one time in 2003-2004 we were literally DES-ing almost everyone - 90% ). Perhaps we are more circumspect now, especially with "off-label "use. We should also be more careful with the use of Plavix post DES. We should ask much more questions after DESing, with whether the patient is taking his plavix. Of course, the standard policy now is plavix for 1 year post-DES, at least. No shortcuts about "I cannot afford Plavix ". If you can afford plavix, then do not use the DES.

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