Date post: | 05-Jan-2016 |
Category: |
Documents |
Upload: | alexander-richard |
View: | 223 times |
Download: | 0 times |
The Pathology of Cardiac Interventions
Dr Stephen Preston
Royal Bournemouth Hospital
Dr Patrick J Gallagher
University of Southampton
Problems for the Pathologist
• As the number of interventions increase all pathologists will perform autopsies on patients with stents
• Finding and dissecting stents can be difficult
• Two questions: is the stent patent? If not is it thrombus or fibrous tissue?
• What is the appearance of the myocardial infarct?
No endothelium
Late DES failure
23 DES cases, died >30 days post procedure
14 (61%) had stent thrombosis (one died of stroke)
7 (30%) had patent stent(s)
4 cardiac deaths
2 (9%) had stent restenosis (both died of AMI/SCD)
3 non-cardiac deaths
Joner M et al, J Am Coll Cardiol 2006;48:193-202
Pathological factors in stent thrombosis
• Delayed endothelial coverage– Necessary for thrombosis, rare in bare metal stents– Maximum mean DES coverage 60-70%– More common with ruptured plaques
• Pro-thrombotic material– Thrombus– Penetration of necrotic plaque core– Hypersensitivity/inflammation?
• Abnormal flow– Malapposition– Restenosis
Limitations to the coroner’s autopsy
• Coroner’s duty:– Who died, when, where and how
• Purpose of autopsy in non-suspicious cases:– Provide a medical cause of death
• Finance– 112 coroners, £71million total budget
• 50% on autopsy, mortuary, toxicology etc
• Human tissue act• Training of pathologists
Solutions
• Improved training for registrars in histopathology
• UK Cardiac Pathology Network
• Chief coroner?
• Medical examiners?
References
• Carlsson J et al. Is late stent thrombosis a real clinical issue? A single-center experience and review of the literature. Clin Res Cardiol 2007;96:86-93.
• Finn AV et al. Vascular responses to drug eluting stents: importance of delayed healing. Arterioscler Thromb Vasc Biol 2007;27:1500-10.
• Finn AV et al. Does underlying plaque morphology play a role in vessel healing after drug-eluting stent implantation? J Am Coll Cardiol Img 2008;1:485-8.
• Joner M et al. Pathology of drug eluting stents in humans. Delayed healing and late thrombotic risk. J Am Coll Cardiol 2006;48:193-202.
• Luescher TF et al. Drug-eluting stent and coronary thrombosis: biological mechanisms and clinical implications. Circulation 2007;115:1051-8.