Abstract
Challenges arise in the care of patients with drug-eluting stents (DES) undergoing noncardiac surgery. The risk of bleeding during surgery must be balanced with the risk of stent thrombosis from interrupted dual antiplatelet therapy. We report a case of a patient with simultaneous stent thrombosis in two coronary arteries following discontinuation of clopidogrel for an elective noncardiac surgery 3 years after DES placement.
1
Case
A 63-year-old diabetic male with coronary artery disease received his first paclitaxel drug-eluting stent (DES) in April 2004 on his middle left anterior descending artery (LAD) after presenting with an anterior ST-segment elevation myocardial infarction (STEMI). He returned 5 months later with chest pain and a non-STEMI. Repeat cardiac catheterization revealed left ventricular ejection fraction of 35% and in-stent restenosis of his prior LAD stent as well as progressive mid–right coronary artery (RCA) disease, both treated with sirolimus DES implants. Later that day, the patient had a documented episode of sustained ventricular tachycardia (VT) and was taken emergently for repeat cardiac catheterization, which revealed patent stents. The patient subsequently received an implantable cardiac defibrillator (ICD) and was discharged home on lifelong dual antiplatelet therapy (DAPT) with aspirin and clopidogrel.
The patient did well until he presented again to the emergency room (ER) in February of 2007 with severe retrosternal chest pain and diffuse ST elevations in the anterior and inferior leads on electrocardiogram ( Fig. 1 ). This event occurred 5 days after an uneventful spinal fixation surgery, which had been preceded by a week of interrupted clopidogrel therapy while remaining on aspirin. In the ER, the patient went into cardiac arrest with episodes of both ventricular fibrillation (VF) and pulseless VT and, after successful resuscitation, was emergently transferred to the cardiac catheterization laboratory where coronary angiogram revealed occlusion of both his mid-RCA and mid-LAD stents consistent with definite stent thrombosis ( Fig. 2 A , C).
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