"Very" very late stent thrombosis: acute myocardial infarction from drug-eluting stent thrombosis more than 5 years after implantation.

A serious long-term complication of drug-eluting stent (DES) implantation is the occurrence of very late stent thrombosis (VLST) beyond 1 year after implantation. While VLST has been observed as late as 3 to 5 years following the initial procedure, it remains unknown whether DES thrombosis is a finite phenomenon that abates over time or is a risk that persists indefinitely. We identified a series of patients who presented with acute myocardial infarction (MI) due to "very" very late stent thrombosis (VVLST), defined as occurring more than 5 years after DES implantation. The study group consisted of 7 patients (6 men and 1 woman), ages 32 to 70 years, who had angiographically confirmed definite VVLST. Six patients were active smokers and 4 were diabetic. The interval between stent implantation and VVLST ranged from 5.6 to 7.1 years. The DES was sirolimus-eluting in 4 patients and paclitaxel-eluting in 3 patients. None of the patients were taking clopidogrel and only 2 patients were taking aspirin at the time of VVLST. Therefore, 5 of the 7 patients were not on any antiplatelet therapy prior to VVLST. The clinical presentation of VVLST was an acute MI in all patients, with ST-segment elevation in 6 of the 7 patients. Six patients were treated successfully by emergent repeat percutaneous coronary intervention and 1 patient who was postoperative from neurosurgery was managed medically. In conclusion, the risk of stent thrombosis persists even beyond 5 years after first-generation DES implantation. These sobering findings underscore the importance of long-term clinical vigilance in these patients and reinforce current PCI guidelines, which recommend continuing at least aspirin indefinitely after DES.