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Managing Recurrent Acute In-Stent Thrombosis: Insights from a Single Case Study
In-stent thrombosis (ISR) is one of the dreaded complications of percutaneous coronary angioplasty. Despite marked reductions in ISR since the transition from bare metal stents to drug-eluting stents, ISR still occurs at a rate of 1%-2% per year.
We present the case of a 64-year-old Caucasian male who was admitted for staged angioplasty after a left heart catheterization had shown significant stenosis to the LAD and mid ramus intermedius. He had DES placed to the mid-LAD and mid-ramus intermedius. Despite being placed on dual antiplatelet therapy after the stent placement, six hours later, he complained of chest pain and EKG showed new ST elevations in leads I, aVL, and V2-V6. Repeat LHC showed thrombosis to recently placed LAD and mid ramus-intermedius stents, so a new set of stents was placed, and the patient was loaded with eptifibatide and then restarted on dual antiplatelet therapy after the procedure.
However, only 48 hours later, the patient started complaining of chest pain again. EKG showed new ischemic changes and a high sensitivity troponin of 5000. He was taken to the catheterization lab, and LHC once again revealed late stenosis of the previously stented LAD and mid-ramus intermedius. He underwent percutaneous coronary angioplasty to these stents. Post-LHC, he was started on prasugrel and aspirin instead of the 2 other times when he was on clopidogrel and aspirin, then ticagrelor and aspirin.
In addition to the dual antiplatelet therapy, he was also started on a Factor X inhibitor, rivaroxaban. Our hypercoagulability investigations did not yield any positive results; however, we found out the patient was on testosterone replacement.
This case is very unique in that we had early re-stenosis of a drug-eluting stent, and it did not only occur once, it occurred twice. One of the questions raised in this unique case is: when you have patients who have early restenosis of their stents, what is the preferred antiplatelet agent, and is a Factor Xa inhibitor indicated in this scenario? In the case of our patient, we went for prasugrel + aspirin + rivaroxaban, and we did not have any re-stenosis.