Abstract 17459: Recurrent In-stent Thrombosis: An Atypical Presentation of Malignancy
Management of acute coronary syndromes most typically involves percutaneous coronary intervention with or without stent placement, and this has significantly improved morbidity and mortality in this syndrome. However, intra-coronary stents can lose their patency due to either in-stent restenosis or in-stent thrombosis (IST). More rarely recurrent in-stent thrombosis (RIST) can occur.
Here we report the case of a 58 year old African American male with a history of human immunodeficiency virus (on highly active antiretroviral therapy), chronic kidney disease, cerebrovascular accident, chronic obstructive pulmonary disease and tobacco abuse. He presented with 7 non-ST-elevation myocardial infarctions, 6 angiographically documented episodes of coronary artery occlusion and 2 episodes of early in-stent and 2 late in-stent thromboses over the span of less than 7-months. This occurred despite reasonable evidence for compliance with optimal medical therapy. His antiplatelet regimen was changed several times until he presented 1-month after his final IST with gastrointestinal bleeding from a fungating partially obstructing well to moderately differentiated invasive adenocarcinoma in the ascending colon. Unfortunately, he expired 2-months later.
Including our patient there have now been 4 reports of early RIST in patients with undiagnosed malignancy. Specific malignancies reported include: prostate, adrenal, renal, bladder, and now gastrointestinal primaries. Trousseau’s syndrome, the prothrombotic state of malignancy, has long been implicated in both venous and arterial thrombosis. We believe this prothrombotic milieu also increases the risk for in-stent thrombosis.
In the setting of malignancy, as with myocardial infarction, delay before diagnosis can be catastrophic. While more data is needed on the topic, for now we suggest that physicians consider aggressive screening for malignancy in patients with IST or RIST.
Author Disclosures: E.C. Klein: None. D.L. Crabbe: None.
- © 2015 by American Heart Association, Inc.