title: Identification of Intrastent Pathology Associated With Late Stent Thrombosis Using Optical Coherence Tomography.
abstract: OBJECTIVE
  To better characterize intrastent pathology using optical coherence tomography (OCT) in patients presenting with late and very late stent thrombosis (LST/VLST).
  
  
  BACKGROUND
  The contribution of specific intrastent pathologies to the development of LST/VLST is not well understood.
  
  
  METHODS
  In this single-center, retrospective, observational study of 796 consecutive patients treated for ST-segment elevation myocardial infarction (STEMI) with primary PCI we identified 57 patients (7.2%) in whom STEMI resulted from LST/VLST. Of the patients with LST/VLST, 21 patients (37%) had OCT performed at the discretion of the operator during PCI for LST/VLST. Independent reviewers performed qualitative offline analysis of OCT images to determine the cause of stent thrombosis defined as the specific intrastent pathology associated with thrombus deposition.
  
  
  RESULTS
  The principal intrastent pathology causing LST/VLST was determined to be stent malapposition in 11 patients (55%), of which 5 (25% of all LST/VLST patents) had findings suggestive of positive vessel remodeling. Neoatherosclerosis was determined to be the cause of LST/VLST in 7 patients (35%). LST/VLST resulted from uncovered stent struts in 2 patients (10%). Among all LST/VLST patients, in-hospital mortality (12.3%) and post-hospital target vessel failure (TVF) or cardiac death (21.7%, median follow-up 1.6 years) remained high. There was a trend towards decreased TVF or cardiac death (7.7% vs. 27.3% P = 0.24) in patients who underwent OCT-guided therapy.
  
  
  CONCLUSIONS
  LST/VLST remains a significant cause of STEMI and is associated with considerable morbidity and mortality. OCT use at the time of PCI consistently identifies significant intrastent pathology with potentially meaningful clinical impact.
authors.affiliation: Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Christopher R
authors.initials: CR
authors.lastname: Jones
authors.affiliation: Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Sameer J
authors.initials: SJ
authors.lastname: Khandhar
authors.affiliation: Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Mohun
authors.initials: M
authors.lastname: Ramratnam
authors.affiliation: Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Suresh R
authors.initials: SR
authors.lastname: Mulukutla
authors.affiliation: Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Oscar C
authors.initials: OC
authors.lastname: Marroquin
authors.affiliation: Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Althouse
authors.affiliation: Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Anjali
authors.initials: A
authors.lastname: Rao
authors.affiliation: Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Koji
authors.initials: K
authors.lastname: Kato
authors.affiliation: Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Ik-Kyung
authors.initials: IK
authors.lastname: Jang
authors.affiliation: Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
authors.forename: Catalin
authors.initials: C
authors.lastname: Toma
mesh_terms: D000368:Aged; D023903:Coronary Restenosis / Q000175:diagnosis / Q000209:etiology / Q000401:mortality; D054855:Drug-Eluting Stents / Q000009:adverse effects*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis / Q000628:therapy*; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods; D015203:Reproducibility of Results; D019233:Retreatment / Q000379:methods / Q000706:statistics & numerical data; D012189:Retrospective Studies; D016019:Survival Analysis; D013927:Thrombosis / Q000175:diagnosis / Q000209:etiology; D013997:Time Factors; D041623:Tomography, Optical Coherence / Q000379:methods; D014481:United States / Q000453:epidemiology