key: cord-0977429-vfc3u4t5
authors: Prieto-Lobato, Alicia; Ramos-Martínez, Raquel; Vallejo-Calcerrada, Nuria; Corbí-Pascual, Miguel; Córdoba-Soriano, Juan G.
title: A Case Series of Stent Thrombosis During the COVID-19 Pandemic
date: 2020-05-27
journal: JACC Case Rep
DOI: 10.1016/j.jaccas.2020.05.029
sha: 2407109a6d1eb6070d2eb533371d704e84685c04
doc_id: 977429
cord_uid: vfc3u4t5

Abstract COVID-19 triggers a hypercoagulable state with a high incidence of thrombotic complications. We have noted a higher than expected incidence of stent thrombosis in these patients.

Advances in PCI techniques, improvement in coronary stent designs, and more effective antithrombotic therapies have made coronary stent thrombosis (ST) a rare complication.

The incidence at 30 days is <1%, whereas late and very late ST rates are 0.5-1% and 0.2-2% per year, respectively (1) . COVID-19 has modified the usual presentation of many diseases as we know them. This disease promotes a sustained prothrombotic state, triggered by the interaction between proinflammatory cytokines, procoagulant factors, and platelets. We have recently observed an increase in ST during the COVID-19 pandemic peak in our center.

A 49-year-old male underwent primary angioplasty for a lateral STEMI 6 hours after the onset of symptoms. Balloon angioplasty in a small ramus intermedius was performed. In order to decrease hospital length of stay, ad hoc PCI was performed in the circumflex artery with two overlapped DES (Videos 1-2). Thirty minutes later, there was new onset of more intense chest pain with marked ST-segment depression in the precordial leads. Acute circumflex artery ST was confirmed by repeat angiography (Video 3). OCT demonstrated in-stent mixed thrombus with mild proximal stent underexpansion and a non-significant dissection of the distal stent edge. Intracoronary tirofiban was effective in reducing thrombus burden and proximal overexpansion of the stent was performed (Videos 4-5). The patient received ASA, ticagrelor and 24hcontinuous infusion of tirofiban after the procedure. He had dry cough with chest x-ray compatible with COVID-19 infection, but no tests were performed since we were at the early stage of the pandemic and the threshold of suspicion was high. The patient was discharged at 4 days. Serology testing 23 days later confirmed that IgG was positive for SARS-CoV-2.

A 71-year-old male was admitted in 2007 due to an inferior STEMI treated with RCA DES. He presented with a high-risk NSTEMI due to very late RCA ST.

Thrombectomy, tirofiban and two DES restored flow. The patient reported fever and cough some days before admission; blood testing and chest x-ray showed COVID-19 compatible findings. The patient remained asymptomatic and no confirmatory tests were performed for the same reason as the first patient. appropriate stent expansion, and non-significant neoatherosclerosis (Video 8). The patient was treated with lopinavir-ritonavir, and despite his age, received ASA and prasugrel as antiplatelet therapy. Ten days later, prasugrel was replaced by clopidogrel (after antiviral treatment was completed) and the patient was discharged.

The COVID-19 pandemic has significantly decreased worldwide interventional cardiology activity. In Spain, cardiac catheterization procedures have been reduced 48%, with a reduction of 40% for primary angioplasty (2) . Similar data have been reported in the USA (3). Compared with the immediate period prior to the pandemic peak (February, 1-23, 2020), we experienced a 38% decrease in PCI at our center between March 15 and April 5, 2020 (31 vs 50). Moreover, we had an increase in the The greater thrombogenic predisposition, both arterial and venous, during COVID-19 has been established. Pathophysiologically, the cytokine storm that occurs 5-7 days after the onset of symptoms promotes the coagulation cascade, as well as platelet activation mediated by interleukin-6 and tissue factor. The latter induces an increase in thrombin and fibrin synthesis, as well as platelet production. Thrombocytosis can occur, as can high levels of D-dimer and fibrinogen, with intravascular disseminated coagulation criteria often fulfilled (4, 5) . Additionally, endothelial damage which might be caused by the virus binding to the angiotensin converting enzyme receptor and the stasis promoted by the permanent inflammation, would complete the Virchow triad criteria (6) .

We present one acute ST and three very late ST cases (Table 1) . Despite no acute COVID-19 testing in two cases, symptomatology and subsequent testing (Figure 3) supported that the patients were infected at the time of ST (Table 2) . 

Predictors of stent thrombosis and their implications for clinical practice

Impacto de la pandemia de COVID-19 sobre la actividad asistencial en cardiología intervencionista en España. REC Interv Cardiol

Reduction in ST-segment elevation cardiac catheterization laboratory activations in the United States during COVID-19 pandemic

The procoagulant pattern of patients with COVID-19 acute respiratory distress syndrome

COVID-19 for the cardiologist: a current review of the virology, clinical epidemiology, cardiac and other clinical manifestations and potential therapeutic strategies

Recomendaciones sobre el tratamiento antitrombótico durante la pandemia COVID-19. Posicionamiento del Grupo de Trabajo de Trombosis Cardiovascular de la Sociedad Española de Cardiología

Restenosis, stent thrombosis, and bleeding complications: navigating between Scylla and Charybdis

OM: Obtuse Marginal Branch, RCA: Right Coronary Artery, LAD: Left Anterior Descending, LVEF: Left Ventricular Ejection Fraction, LVD: Left Ventricular Dysfunction, PAD: Peripheral Artery Disease, PCI: Percutaneous Coronary Intervention, SO 2 : Oxygen Saturation