Late Angiographic Stent Thrombosis (LAST): The Cloud Behind the Drug-Eluting Stent Silver Lining?
- Volume 19 - Issue 9 - September, 2007
- Posted on: 8/1/08
- 0 Comments
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In December, 2006, the Food and Drug Administration issued an expert concensus panel statement strongly recommending a minimum of 1 year of DAT post-DES implantation, for both brands. They further opined that while DES are associated with a slightly higher risk of LAST, this is offset by the significant reduction in restenosis and TLR, resulting in no net increase in overall MACE. Moreover, careful evaluation for contraindications to prolonged DAT as well as meticulous stent deployment technique were also stressed. In specific, adequate stent strut apposition and appropriate stent sizing allow for maximization of laminar coronary flow and minimization of thrombotic nidus.63 Additionally, judicious use of adjuctive devices such as intravascular ultrasound and debulking therapies can be valuable aides in optimization of DES results.
The issue of pre-PCI informed consent is receiving increasing scrutiny. It is crucial that patients understand the differences in rates and consequences of both ISR and stent thrombosis for DES and BMS. Clearly, patients with a higher likelihood of DAT discontinuation due to upcoming noncardiac surgery, financial limitations or other compliance issues should be considered for BMS implantation. Thus, despite the initial fervor, the exact role of the currently available DES remains unresolved. Further data on patient selection as well as clinical trials involving novel platforms will hopefully dispel or at least diminish the cloud of LAST from the DES silver lining.