Conversations in Cardiology: Uncovered Struts on OCT After 12 Years?

Morton Kern, MD, of VA Long Beach Healthcare System and University of California, Irvine, often engages his colleagues via email in brief, informal dialogue on clinically relevant topics in interventional cardiology. With permission from the participants, TCTMD presents their conversations for the benefit of the cardiology community. Your feedback is welcome—feel free to comment at the bottom of the page.

Peter Pelikan, MD (Pacific Heart Institute, Santa Monica, CA), asks:

I have a 70-year-old male who had a Taxus stent in the mid RCA placed in 2007. OCT shows uncovered stent struts for maybe a quarter of the stent length.

Continue dual antiplatelet therapy (DAPT) for the evil Taxus stent?

Kern replies:

He's been on DAPT 12 years and still has uncovered stents by OCT without evidence of thrombus. If he needs to stop DAPT, it'd probably be ok. There must be some fibrin coating on the stents that even OCT can’t see to prevent thrombus formation by this time. I think these late uncovered struts could be a reportable case.

Gregg W. Stone, MD (Icahn School of Medicine at Mount Sinai, New York, NY), replies:

I agree that it’s a reportable case. There’s no guarantee that fibrin is coating the stent struts or even if it was that it would be protective. If the patient is tolerating the clopidogrel well, I’d continue it. If anything, I would consider stopping aspirin (ideally after a point-of-care assay demonstrating responsiveness to clopidogrel).

John A. Bittl, MD (AdventHealth Ocala, FL), replies:

I would probably continue clopidogrel indefinitely, with aspirin being optional.

However, I respectfully question the need for point-of-care testing when you have 7 years of clinical evidence in this patient that clopidogrel was effective. What additional evidence could be learned from a laboratory test?

Mitchell W. Krucoff, MD (Duke University Medical Center, Durham, NC), replies:

If clinically silent, I agree to continue clopidogrel when it has already proven itself. Maybe bigger question is the role of aspirin . . . but if stable maybe just stay the course.

Why did he undergo cath and what else was found—was there another “culprit”?

Kirk Garratt, MD (Christiana Care Health System, Newark, DE), replies:

Troubling. The OCT suggests greater risk, but we have no idea how to manage it best. I’d hate to take a chance on stopping his clopidogrel, just because he’s been on it a long time. On the other hand, everybody has to stop DAPT at some point, and stopping it when he’s acutely injured or ill is probably the most dangerous time to do it – heightened systemic inflammatory state and all that. I’d assess his DAPT Score (actually fits this situation) to understand his expected thrombosis/bleeding risk profile before making any change, and if < 2 then I’d ditch his aspirin and continue clopidogrel as a single agent. But I have no proof this is best. Not sure that functional antiplatelet testing has a role.

Stone replies:

Presuming the long-term evidence that clopidogrel is effective is on an aspirin plus clopidogrel regimen, I would be slightly hesitant in stopping the aspirin if clopidogrel is pharmacodynamically ineffective—then there would be minimal to no antiplatelet coverage. But I acknowledge there is little data to support this approach.

Samuel Butman, MD (Heart & Vascular Center of Northern Arizona, Cottonwood), replies:

I read all the comments and, of course, agree.

Really no one would change the status quo with the additional knowledge, but at the same time, if there was a bleeding issue now, I think one could easily feel comfortable stopping either or even both antiplatelet agents, as well, for the reasons outlined by the others.

Truly a unique observation.

Neal Kleiman, MD (Houston Methodist Hospital, Texas), replies:

I agree with John. If the patient is tolerating DAPT and there is serious concern that the stent isn’t “passivated,” why change course?