Late stent thrombosis: Considerations and practical advice for the use of drug-eluting stents: A report from the society for cardiovascular angiography and interventions drug-eluting stent task force

In light of the observed small increased incidence of very late thrombosis seen after DES implantation we advise the following: 1. Prior to any stent implantation, patients should meet criteria for PCI according to published guidelines. 2. The decision to implant a DES vs. an alternative revascularization strategy (including bare metal stents or surgical revascularization) must be made on an individual patient basis after consideration of the relative risks and benefits of each therapy. 3. Careful evaluation of the patient with respect to compliance and the risks of long-term dual antiplatelet therapy must be performed prior to implanting a DES. 4. Careful attention must be paid to stent implantation technique. The use of intravascular ultrasound, screening for calcification, and careful lesion preparation are encouraged. 5. Following DES implantation, dual antiplatelet therapy should be prescribed for no less than 3 months (Cypher) or 6 months (Taxus) for patients meeting the FDA approved indications. In such patients who are not at high risk for bleeding, we strongly recommend the continuation of dual antiplatelet therapy for 12 months. Until the issue of very late stent thrombosis is further studied, we recommend that patients at higher risk for stent thrombosis be considered for dual antiplatelet therapy for longer than 12 months after careful review of the risks and benefits. 6. The discontinuation of dual antiplatelet therapy (either transiently or permanently) requires careful consideration of the relative risks of continuation (primarily bleeding and cost) and the potential risks of late stent thrombosis. This decision must be individualized. There are no tested "bridging" strategies. 7. The medical decision making process, risks and benefits of all appropriate therapies, and the need for dual antiplatelet therapy should be discussed with the patient and documented in the medical record. 8. Patients should be reassured that the implantation of a DES, after careful consideration with their physician, remains a very effective method for the treatment for symptoms associated with the disabling problem of coronary artery disease. © 2007 Wiley-Liss, Inc.