Lost contact with vessel wall, signed contract with stent thrombosis?

This editorial refers to ‘Impact of incomplete stent apposition on long-term clinical outcome after drug-eluting stent implantation’, by S. Cook et al. , doi:10.1093/eurheartj/ehr484Drug-eluting stents (DES) represent the most successful approach in preventing restenosis after percutaneous coronary interventions (PCIs).1 Many believe, however, that reduction of neointima formation is associated with a worrisome side effect, an increased risk of very late stent thrombosis, at least as observed with early DES technologies.2 An adverse vessel wall reaction to two DES components—drug and polymer—has been called into question.3–5 On balance, an increased risk for very late stent thrombosis seems to be the price to be paid for the dramatic reduction of restenosis with DES of earlier generations. A similar therapeutic imperfection related to PCI also exists for the adjunct antithrombotic therapy: an increased risk of bleeding is the price still to be paid for the prevention of stent thrombosis. Thus, identification of that very small fraction of patients carrying an excessive risk of DES thrombosis, and probably requiring prolonged dual antiplatelet therapy (DAPT), has the potential of minimizing exposure to an increased risk of bleeding.A multitude of studies have been dedicated to the assessment of factors predictive of DES thrombosis. Premature discontinuation of ADP receptor antagonists has emerged as one of the most prominent predictors,6 although little is known about the optimal duration of DAPT after DES.7 Certain clinical and lesion characteristics along with a poor platelet response to clopidogrel8 have also been identified as correlates of DES thrombosis risk.9 Another direction of investigations is based on intravascular imaging techniques. A new parameter, late incomplete stent apposition (ISA), has attracted the attention of both intravascular ultrasound (IVUS) and optical coherence tomography (OCT) studies as a candidate predictor of late DES thrombosis.10, …