Official reprint from UpToDate®
www.uptodate.com ©2015 UpToDate®

Coronary artery stent thrombosis: Incidence and risk factors

Donald Cutlip, MD
J Dawn Abbott, MD, FACC
Section Editors
Christopher P Cannon, MD
Stephan Windecker, MD
Deputy Editor
Gordon M Saperia, MD, FACC


Coronary artery stents are used in the majority of patients who undergo percutaneous coronary intervention (PCI), as they significantly reduce the need for repeat target vessel revascularization compared to balloon angioplasty. (See "Intracoronary stent restenosis", section on 'Incidence of restenosis'.)

Stent thrombosis is an uncommon but serious complication that almost always presents as death or a large non-fatal myocardial infarction (MI), usually with ST elevation. It is estimated that less than 10 percent of cardiac deaths after stent placement are attributable to stent thrombosis, with most of the remainder being due to disease progression [1]. This issue is discussed in detail separately. (See "Drug-eluting compared to bare metal intracoronary stents", section on 'DES compared to BMS'.)

Stent thrombosis can occur acutely (within 24 hours), subacutely (within 30 days), or as late as one year (late) or more (very late) after stent placement. Stent thrombosis within the first year appears to occur with similar frequency in patients with bare metal stents (BMS) or drug-eluting stents (DES), as long as patients are treated with dual antiplatelet therapy (aspirin plus a platelet P2Y12 receptor blocker) for the recommended duration. The period of risk requiring dual antiplatelet therapy (DAPT) is longer with DES, due at least in part to delayed neointimal coverage. (See 'Very late stent thrombosis' below.)

General issues related to stent thrombosis will be reviewed in this topic. The prevention and management of stent thrombosis are discussed separately. (See "Antiplatelet therapy after coronary artery stenting" and "Coronary artery stent thrombosis: Clinical presentation and management".)


The randomized clinical trials that have evaluated the frequency of coronary artery stent thrombosis have not used a uniform definition in their protocols, leading to difficulty in comparing the different studies. The following definitions were used in most studies and, for the purpose of this discussion, will be called the protocol definition [2]:


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Dec 2014. | This topic last updated: Oct 7, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2015 UpToDate, Inc.
  1. Stone GW, Moses JW, Ellis SG, et al. Safety and efficacy of sirolimus- and paclitaxel-eluting coronary stents. N Engl J Med 2007; 356:998.
  2. Spaulding C, Daemen J, Boersma E, et al. A pooled analysis of data comparing sirolimus-eluting stents with bare-metal stents. N Engl J Med 2007; 356:989.
  3. Cutlip DE, Windecker S, Mehran R, et al. Clinical end points in coronary stent trials: a case for standardized definitions. Circulation 2007; 115:2344.
  4. Brener SJ, Cristea E, Kirtane AJ, et al. Intra-procedural stent thrombosis: a new risk factor for adverse outcomes in patients undergoing percutaneous coronary intervention for acute coronary syndromes. JACC Cardiovasc Interv 2013; 6:36.
  5. Généreux P, Stone GW, Harrington RA, et al. Impact of intraprocedural stent thrombosis during percutaneous coronary intervention: insights from the CHAMPION PHOENIX Trial (Clinical Trial Comparing Cangrelor to Clopidogrel Standard of Care Therapy in Subjects Who Require Percutaneous Coronary Intervention). J Am Coll Cardiol 2014; 63:619.
  6. Chieffo A, Bonizzoni E, Orlic D, et al. Intraprocedural stent thrombosis during implantation of sirolimus-eluting stents. Circulation 2004; 109:2732.
  7. Lüscher TF, Steffel J, Eberli FR, et al. Drug-eluting stent and coronary thrombosis: biological mechanisms and clinical implications. Circulation 2007; 115:1051.
  8. Palmerini T, Kirtane AJ, Serruys PW, et al. Stent thrombosis with everolimus-eluting stents: meta-analysis of comparative randomized controlled trials. Circ Cardiovasc Interv 2012; 5:357.
  9. Daemen J, Wenaweser P, Tsuchida K, et al. Early and late coronary stent thrombosis of sirolimus-eluting and paclitaxel-eluting stents in routine clinical practice: data from a large two-institutional cohort study. Lancet 2007; 369:667.
  10. Iakovou I, Schmidt T, Bonizzoni E, et al. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA 2005; 293:2126.
  11. Airoldi F, Colombo A, Morici N, et al. Incidence and predictors of drug-eluting stent thrombosis during and after discontinuation of thienopyridine treatment. Circulation 2007; 116:745.
  12. Lagerqvist B, Carlsson J, Fröbert O, et al. Stent thrombosis in Sweden: a report from the Swedish Coronary Angiography and Angioplasty Registry. Circ Cardiovasc Interv 2009; 2:401.
  13. van Werkum JW, Heestermans AA, Zomer AC, et al. Predictors of coronary stent thrombosis: the Dutch Stent Thrombosis Registry. J Am Coll Cardiol 2009; 53:1399.
  14. Leon MB, Baim DS, Popma JJ, et al. A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent Anticoagulation Restenosis Study Investigators. N Engl J Med 1998; 339:1665.
  15. Schühlen H, Kastrati A, Pache J, et al. Incidence of thrombotic occlusion and major adverse cardiac events between two and four weeks after coronary stent placement: analysis of 5,678 patients with a four-week ticlopidine regimen. J Am Coll Cardiol 2001; 37:2066.
  16. Cutlip DE, Baim DS, Ho KK, et al. Stent thrombosis in the modern era: a pooled analysis of multicenter coronary stent clinical trials. Circulation 2001; 103:1967.
  17. Fischman DL, Leon MB, Baim DS, et al. A randomized comparison of coronary-stent placement and balloon angioplasty in the treatment of coronary artery disease. Stent Restenosis Study Investigators. N Engl J Med 1994; 331:496.
  18. Leon MB, Wong SC. Intracoronary stents. A breakthrough technology or just another small step? Circulation 1994; 89:1323.
  19. Serruys PW, de Jaegere P, Kiemeneij F, et al. A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease. Benestent Study Group. N Engl J Med 1994; 331:489.
  20. Sutton JM, Ellis SG, Roubin GS, et al. Major clinical events after coronary stenting. The multicenter registry of acute and elective Gianturco-Roubin stent placement. The Gianturco-Roubin Intracoronary Stent Investigator Group. Circulation 1994; 89:1126.
  21. Moussa I, Di Mario C, Reimers B, et al. Subacute stent thrombosis in the era of intravascular ultrasound-guided coronary stenting without anticoagulation: frequency, predictors and clinical outcome. J Am Coll Cardiol 1997; 29:6.
  22. Cheneau E, Leborgne L, Mintz GS, et al. Predictors of subacute stent thrombosis: results of a systematic intravascular ultrasound study. Circulation 2003; 108:43.
  23. Moreno R, Fernández C, Hernández R, et al. Drug-eluting stent thrombosis: results from a pooled analysis including 10 randomized studies. J Am Coll Cardiol 2005; 45:954.
  24. Ferrari E, Benhamou M, Cerboni P, Marcel B. Coronary syndromes following aspirin withdrawal: a special risk for late stent thrombosis. J Am Coll Cardiol 2005; 45:456.
  25. Scheller B, Hennen B, Pohl A, et al. Acute and subacute stent occlusion; risk-reduction by ionic contrast media. Eur Heart J 2001; 22:385.
  26. Ellis SG, Colombo A, Grube E, et al. Incidence, timing, and correlates of stent thrombosis with the polymeric paclitaxel drug-eluting stent: a TAXUS II, IV, V, and VI meta-analysis of 3,445 patients followed for up to 3 years. J Am Coll Cardiol 2007; 49:1043.
  27. Kotani J, Awata M, Nanto S, et al. Incomplete neointimal coverage of sirolimus-eluting stents: angioscopic findings. J Am Coll Cardiol 2006; 47:2108.
  28. Awata M, Kotani J, Uematsu M, et al. Serial angioscopic evidence of incomplete neointimal coverage after sirolimus-eluting stent implantation: comparison with bare-metal stents. Circulation 2007; 116:910.
  29. Sarno G, Lagerqvist B, Fröbert O, et al. Lower risk of stent thrombosis and restenosis with unrestricted use of 'new-generation' drug-eluting stents: a report from the nationwide Swedish Coronary Angiography and Angioplasty Registry (SCAAR). Eur Heart J 2012; 33:606.
  30. Roiron C, Sanchez P, Bouzamondo A, et al. Drug eluting stents: an updated meta-analysis of randomised controlled trials. Heart 2006; 92:641.
  31. Mauri L, Hsieh WH, Massaro JM, et al. Stent thrombosis in randomized clinical trials of drug-eluting stents. N Engl J Med 2007; 356:1020.
  32. Faxon DP. Very late stent thrombosis and late target lesion revascularization: no end in sight. Circulation 2012; 125:562.
  33. Wenaweser P, Daemen J, Zwahlen M, et al. Incidence and correlates of drug-eluting stent thrombosis in routine clinical practice. 4-year results from a large 2-institutional cohort study. J Am Coll Cardiol 2008; 52:1134.
  34. Jensen LO, Tilsted HH, Thayssen P, et al. Paclitaxel and sirolimus eluting stents versus bare metal stents: long-term risk of stent thrombosis and other outcomes. From the Western Denmark Heart Registry. EuroIntervention 2010; 5:898.
  35. Kimura T, Morimoto T, Nakagawa Y, et al. Very late stent thrombosis and late target lesion revascularization after sirolimus-eluting stent implantation: five-year outcome of the j-Cypher Registry. Circulation 2012; 125:584.
  36. Tandjung K, Sen H, Lam MK, et al. Clinical outcome following stringent discontinuation of dual antiplatelet therapy after 12 months in real-world patients treated with second-generation zotarolimus-eluting resolute and everolimus-eluting Xience V stents: 2-year follow-up of the randomized TWENTE trial. J Am Coll Cardiol 2013; 61:2406.
  37. Aoki J, Lansky AJ, Mehran R, et al. Early stent thrombosis in patients with acute coronary syndromes treated with drug-eluting and bare metal stents: the Acute Catheterization and Urgent Intervention Triage Strategy trial. Circulation 2009; 119:687.
  38. Cook S, Windecker S. Early stent thrombosis: past, present, and future. Circulation 2009; 119:657.
  39. Wiviott SD, Braunwald E, McCabe CH, et al. Intensive oral antiplatelet therapy for reduction of ischaemic events including stent thrombosis in patients with acute coronary syndromes treated with percutaneous coronary intervention and stenting in the TRITON-TIMI 38 trial: a subanalysis of a randomised trial. Lancet 2008; 371:1353.
  40. De Luca G, Dirksen MT, Spaulding C, et al. Drug-eluting vs bare-metal stents in primary angioplasty: a pooled patient-level meta-analysis of randomized trials. Arch Intern Med 2012; 172:611.
  41. Di Lorenzo E, Sauro R, Varricchio A, et al. Randomized comparison of everolimus-eluting stents and sirolimus-eluting stents in patients with ST elevation myocardial infarction: RACES-MI trial. JACC Cardiovasc Interv 2014; 7:849.
  42. Ferreira-González I, Marsal JR, Ribera A, et al. Background, incidence, and predictors of antiplatelet therapy discontinuation during the first year after drug-eluting stent implantation. Circulation 2010; 122:1017.
  43. Cayla G, Hulot JS, O'Connor SA, et al. Clinical, angiographic, and genetic factors associated with early coronary stent thrombosis. JAMA 2011; 306:1765.
  44. Urban P, Gershlick AH, Guagliumi G, et al. Safety of coronary sirolimus-eluting stents in daily clinical practice: one-year follow-up of the e-Cypher registry. Circulation 2006; 113:1434.
  45. Spertus JA, Kettelkamp R, Vance C, et al. Prevalence, predictors, and outcomes of premature discontinuation of thienopyridine therapy after drug-eluting stent placement: results from the PREMIER registry. Circulation 2006; 113:2803.
  46. Finn AV, Joner M, Nakazawa G, et al. Pathological correlates of late drug-eluting stent thrombosis: strut coverage as a marker of endothelialization. Circulation 2007; 115:2435.
  47. Nakamura S, Colombo A, Gaglione A, et al. Intracoronary ultrasound observations during stent implantation. Circulation 1994; 89:2026.
  48. Goldberg SL, Colombo A, Nakamura S, et al. Benefit of intracoronary ultrasound in the deployment of Palmaz-Schatz stents. J Am Coll Cardiol 1994; 24:996.
  49. Colombo A, Hall P, Nakamura S, et al. Intracoronary stenting without anticoagulation accomplished with intravascular ultrasound guidance. Circulation 1995; 91:1676.
  50. Grines CL, Bonow RO, Casey DE Jr, et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation 2007; 115:813.
  51. Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med 2009; 360:961.
  52. Bouman HJ, van Werkum JW, Breet NJ, et al. A case-control study on platelet reactivity in patients with coronary stent thrombosis. J Thromb Haemost 2011; 9:909.
  53. Guagliumi G, Sirbu V, Musumeci G, et al. Examination of the in vivo mechanisms of late drug-eluting stent thrombosis: findings from optical coherence tomography and intravascular ultrasound imaging. JACC Cardiovasc Interv 2012; 5:12.
  54. Joner M, Finn AV, Farb A, et al. Pathology of drug-eluting stents in humans: delayed healing and late thrombotic risk. J Am Coll Cardiol 2006; 48:193.
  55. Matsumoto D, Shite J, Shinke T, et al. Neointimal coverage of sirolimus-eluting stents at 6-month follow-up: evaluated by optical coherence tomography. Eur Heart J 2007; 28:961.
  56. van Beusekom HM, Saia F, Zindler JD, et al. Drug-eluting stents show delayed healing: paclitaxel more pronounced than sirolimus. Eur Heart J 2007; 28:974.
  57. Yamaji K, Inoue K, Nakahashi T, et al. Bare metal stent thrombosis and in-stent neoatherosclerosis. Circ Cardiovasc Interv 2012; 5:47.
  58. Nakazawa G, Otsuka F, Nakano M, et al. The pathology of neoatherosclerosis in human coronary implants bare-metal and drug-eluting stents. J Am Coll Cardiol 2011; 57:1314.
  59. Moses JW, Leon MB, Popma JJ, et al. Sirolimus-eluting stents versus standard stents in patients with stenosis in a native coronary artery. N Engl J Med 2003; 349:1315.
  60. Beohar N, Davidson CJ, Kip KE, et al. Outcomes and complications associated with off-label and untested use of drug-eluting stents. JAMA 2007; 297:1992.
  61. Win HK, Caldera AE, Maresh K, et al. Clinical outcomes and stent thrombosis following off-label use of drug-eluting stents. JAMA 2007; 297:2001.
  62. Rodriguez AE, Mieres J, Fernandez-Pereira C, et al. Coronary stent thrombosis in the current drug-eluting stent era: insights from the ERACI III trial. J Am Coll Cardiol 2006; 47:205.
  63. Kuchulakanti PK, Chu WW, Torguson R, et al. Correlates and long-term outcomes of angiographically proven stent thrombosis with sirolimus- and paclitaxel-eluting stents. Circulation 2006; 113:1108.
  64. Ong AT, Hoye A, Aoki J, et al. Thirty-day incidence and six-month clinical outcome of thrombotic stent occlusion after bare-metal, sirolimus, or paclitaxel stent implantation. J Am Coll Cardiol 2005; 45:947.
  65. Ge L, Airoldi F, Iakovou I, et al. Clinical and angiographic outcome after implantation of drug-eluting stents in bifurcation lesions with the crush stent technique: importance of final kissing balloon post-dilation. J Am Coll Cardiol 2005; 46:613.
  66. Williams DO, Abbott JD. Bifurcation intervention: is it crush time yet? J Am Coll Cardiol 2005; 46:621.
  67. Collins SD, Torguson R, Gaglia MA Jr, et al. Does black ethnicity influence the development of stent thrombosis in the drug-eluting stent era? Circulation 2010; 122:1085.
  68. Lemos PA. Hidden drugs, hidden risks--is cocaine use a new risk factor for stent thrombosis? Catheter Cardiovasc Interv 2007; 69:959.
  69. McKee SA, Applegate RJ, Hoyle JR, et al. Cocaine use is associated with an increased risk of stent thrombosis after percutaneous coronary intervention. Am Heart J 2007; 154:159.
  70. Park DW, Yun SC, Lee JY, et al. C-reactive protein and the risk of stent thrombosis and cardiovascular events after drug-eluting stent implantation. Circulation 2009; 120:1987.
  71. Nebeker JR, Virmani R, Bennett CL, et al. Hypersensitivity cases associated with drug-eluting coronary stents: a review of available cases from the Research on Adverse Drug Events and Reports (RADAR) project. J Am Coll Cardiol 2006; 47:175.
  72. Cook S, Wenaweser P, Togni M, et al. Incomplete stent apposition and very late stent thrombosis after drug-eluting stent implantation. Circulation 2007; 115:2426.
  73. Lee CW, Kang SJ, Park DW, et al. Intravascular ultrasound findings in patients with very late stent thrombosis after either drug-eluting or bare-metal stent implantation. J Am Coll Cardiol 2010; 55:1936.
  74. Weisz G, Leon MB, Holmes DR Jr, et al. Five-year follow-up after sirolimus-eluting stent implantation results of the SIRIUS (Sirolimus-Eluting Stent in De-Novo Native Coronary Lesions) Trial. J Am Coll Cardiol 2009; 53:1488.
  75. Palmerini T, Biondi-Zoccai G, Della Riva D, et al. Stent thrombosis with drug-eluting and bare-metal stents: evidence from a comprehensive network meta-analysis. Lancet 2012; 379:1393.
  76. Ormiston JA, Webster MW. Stent thrombosis: has the firestorm been extinguished? Lancet 2012; 379:1368.
  77. Bangalore S, Kumar S, Fusaro M, et al. Short- and long-term outcomes with drug-eluting and bare-metal coronary stents: a mixed-treatment comparison analysis of 117 762 patient-years of follow-up from randomized trials. Circulation 2012; 125:2873.
  78. Lagerqvist B, James SK, Stenestrand U, et al. Long-term outcomes with drug-eluting stents versus bare-metal stents in Sweden. N Engl J Med 2007; 356:1009.
  79. Bavry AA, Kumbhani DJ, Helton TJ, Bhatt DL. What is the risk of stent thrombosis associated with the use of paclitaxel-eluting stents for percutaneous coronary intervention?: a meta-analysis. J Am Coll Cardiol 2005; 45:941.
  80. Kastrati A, Dibra A, Eberle S, et al. Sirolimus-eluting stents vs paclitaxel-eluting stents in patients with coronary artery disease: meta-analysis of randomized trials. JAMA 2005; 294:819.
  81. Caixeta A, Leon MB, Lansky AJ, et al. 5-year clinical outcomes after sirolimus-eluting stent implantation insights from a patient-level pooled analysis of 4 randomized trials comparing sirolimus-eluting stents with bare-metal stents. J Am Coll Cardiol 2009; 54:894.
  82. Kastrati A, Mehilli J, Pache J, et al. Analysis of 14 trials comparing sirolimus-eluting stents with bare-metal stents. N Engl J Med 2007; 356:1030.
  83. Farb A, Boam AB. Stent thrombosis redux--the FDA perspective. N Engl J Med 2007; 356:984.
  84. Kaltoft A, Jensen LO, Maeng M, et al. 2-year clinical outcomes after implantation of sirolimus-eluting, paclitaxel-eluting, and bare-metal coronary stents: results from the WDHR (Western Denmark Heart Registry). J Am Coll Cardiol 2009; 53:658.
  85. Stettler C, Wandel S, Allemann S, et al. Outcomes associated with drug-eluting and bare-metal stents: a collaborative network meta-analysis. Lancet 2007; 370:937.
  86. Schömig A, Dibra A, Windecker S, et al. A meta-analysis of 16 randomized trials of sirolimus-eluting stents versus paclitaxel-eluting stents in patients with coronary artery disease. J Am Coll Cardiol 2007; 50:1373.
  87. Galløe AM, Thuesen L, Kelbaek H, et al. Comparison of paclitaxel- and sirolimus-eluting stents in everyday clinical practice: the SORT OUT II randomized trial. JAMA 2008; 299:409.
  88. Stefanini GG, Windecker S. Stent thrombosis: no longer an issue with newer-generation drug-eluting stents? Circ Cardiovasc Interv 2012; 5:332.
  89. Räber L, Magro M, Stefanini GG, et al. Very late coronary stent thrombosis of a newer-generation everolimus-eluting stent compared with early-generation drug-eluting stents: a prospective cohort study. Circulation 2012; 125:1110.
  90. Park DW, Kim YH, Song HG, et al. Outcomes after unrestricted use of everolimus-eluting and sirolimus-eluting stents in routine clinical practice: a multicenter, prospective cohort study. Circ Cardiovasc Interv 2012; 5:365.
  91. Silber S, Windecker S, Vranckx P, et al. Unrestricted randomised use of two new generation drug-eluting coronary stents: 2-year patient-related versus stent-related outcomes from the RESOLUTE All Comers trial. Lancet 2011; 377:1241.
  92. Serruys PW, Silber S, Garg S, et al. Comparison of zotarolimus-eluting and everolimus-eluting coronary stents. N Engl J Med 2010; 363:136.
  93. Camenzind E, Wijns W, Mauri L, et al. Stent thrombosis and major clinical events at 3 years after zotarolimus-eluting or sirolimus-eluting coronary stent implantation: a randomised, multicentre, open-label, controlled trial. Lancet 2012; 380:1396.