Recurrent simultaneous two-vessel very late stent thrombosis

Abstract

Background: Stent thrombosis is catastrophic. New-generation drug eluting stents (DES) had a signifi cant improvement in the effi cacy and especially safety. Very late stent thrombosis is a rare complication, however, even rarer is to have a simultaneous two-vessel very late stent thrombosis with second-generation DESs. Case presentation: A 43-year-old male was admitted to our hospital in 2018 because of non-ST elevation myocardial infarction (NSTEMI) due to signifi cant lesions on the proximal left anterior descending (LAD) and the circumfl ex (Cx) arteries treated with the implantation of two drug eluting stents. After 2 years of wellbeing, he was readmitted because of an anterior ST-elevation myocardial infarction (STEMI). Coronary angiography showed severe stenosis of the two previously treated arteries. Primary percutaneous coronary intervention (PCI) was done by the implantation on the LAD and on the CX of sirolimus-eluting stents. 100 mg aspirin and 75 mg clopidogrel were administered to the patient then for one year. In April 2021, the patient consulted the emergency department because of a continuous oppressive chest pain. ECG showed an anterior STEMI. He entered the catheterization laboratory with 2 h of total delay since symptom onset. To our surprise, the culprit lesion was on the same two vessels. We implanted on the LAD a sirolimus-eluting stent 4 × 25 mm and the Cx lesion was treated with a non-compliant balloon 3 × 20 mm infl ated at 14 atm. On both episodes, the patient was on single antiplatelet therapy with aspirin after 12 months of DAPT, and no triggering factor had been identifi ed except for a severe emotional distress preceding both events. Conclusion: VLST is a catastrophic event due to complex mechanisms. This case describes a rare form of recurrent VLST and is in line with the recent guidelines that recommend identifying a category of patients with high ischemic risk needing a prolonged double antiplatelet treatment.