Impact Factor: 1.4


Scientific letter

REC Interv Cardiol. 2023;5:142-150

Role of drug-coated balloon in the management of very late stent thrombosis

Papel del balón farmacoactivo en el tratamiento de la trombosis muy tardía de stent

José Valencia, Francisco Torres-Saura, Fernando Torres-Mezcua, Pascual Bordes, Javier Pineda, and Juan Miguel Ruiz-Nodar

Unidad de Hemodinámica, Servicio de Cardiología, Hospital General Universitario Dr. Balmis, Alicante, Spain

To the Editor,

Very late stent thrombosis—the one occurring, at least, 1 year after stenting—is a rare complication of tremendous clinical relevance. The mechanisms underlying its physiopathology have been widely studied thanks to the use of intracoronary imaging modalities, especially optical coherence tomography. The 2 main mechanisms of action found are, in the first place, neoatherosclerosis, and secondly, no strut endothelization.1 Despite of this, its approach is still under discussion and focused on resolution or minimization of the factors leading to its appearance.

On the other hand, drug-coated balloon (DCB) has been part of the therapeutic armamentarium of interventional cardiologists for quite some time. Currently, its main indications are to treat in-stent restenosis, and small vessel de novo coronary artery lesions. New indications are emerging like bifurcations (especially of the side branch) and large vessel de novo lesions. However, there is a clinical setting where its use has instilled quite a few serious doubts: ST-segment elevation acute coronary syndrome (STEACS). Since plaque rupture followed by thrombosis is its main pathogenic mechanism and it’s different from the therapeutic target of DCB—the inhibition of neointimal proliferation—the use of DCB to treat STEACS is ill-advised. Former studies on this matter have proven so.2 However, isolated, and well-designed studies have obtained good results like the REVELATION.3

However, in very late stent thrombosis—the one associated with the thrombotic phenomenon per se—other pathogenic processes are involved like restenotic lesions and neoatherosclerosis, which could respond to DCB therapy even with a lower risk of complications compared to new stenting since this approach is less aggressive and avoids stenting multiple overlapping stents in the culprit vessel.

This is the first series ever reported of patients with very late stent thrombosis treated with DCB. All of them signed the informed consent form, and received the approval of our hospital ethics committee.

Table 1 shows the clinical, anatomical, and procedural characteristics of the 6 patients included. We should mention the very late onset of stent thrombosis that occurs in 1 of the cases occurred 19 years after the index procedure. A total of 4 patients had complete vessel thrombosis. In all of them percutaneous thrombectomy was performed unlike in the other 2 who had partial thrombosis with baseline TIMI (Thrombolysis in Myocardial Infarction) grade-3 flow. We should mention that in 2 out of the 6 patients significant changes were reportes regarding measurements taken on the days that preceded the onset of STEACS. In the first patient, single antiplatelet therapy was withdrawn due to a scheduled dental procedure while in the second patient, dual antiplatelet therapy was changed for single antiplatelet therapy plus oral antiacoagulation due to the presence of deep venous thrombosis. In the only patient treated with optical coherence tomography, neoatherosclerosis was identified as the pathogenic mechanism of thrombosis (figure 1 and figure 2). All the lesions received proper preparation with different predilatation and plaque modification devices before using the DCB, the SeQuent Please Neo with paclitaxel coating technology (BBraun, Germany) in all cases. No adverse events were ever reported at a median follow-up of 6 months.

Table 1. Clinical and procedural characteristics

Patient #1 Patient #2 Patient #3 Patient #4 Patient #5 Patient #6
Sex Woman Man Man Man Man Man
Age (years) 71 81 83 52 63 75
Hypertension Yes Yes Yes Yes Yes No
Diabetes No Yes No No No No
Dyslipidemia Yes Yes Yes Yes Yes Yes
Smoking Yes Former smoker Former smoker Yes Former smoker Former smoker
Kidney disease No (Cr, 0.79) No (Cr, 0.78) No (Cr, 1.02) No (Cr, 1.02) No (Cr, 1.13) No (Cr, 0.98)
Years since stenting 19 3 4 6 15 10
Previous treatment ASA NOA ASA ASA Clopidogrel NOA + clopidogrel
Location of culprit lesion Mid-right coronary artery Mid-left anterior descending coronary artery Saphenous vein graft Distal left circumflex artery Diagonal branch Mid-right coronary artery
Early TIMI grade flow 0 0 3 0 3 0
Predilatation device Scoring NC Cutting + NC Scoring + cutting NC NC
Final TIMI grade flow 3 3 3 3 3 3
Intracoronary images No No No Yes No No
Size of DCB used 3.5 2.5 + 3 4 3 2.5 3
Treatment at discharge ASA + prasugrel NOA + ASA + clopidogrel ASA + ticagrelor ASA + ticagrelor ASA + ticagrelor NOA + ASA + clopidogrel
Follow-up (months) 10 9 6 6 3 2
Adverse events at follow-up No No No No No No

ASA, acetylsalicylic acid; Cr, plasma creatinine concentration (mg/dL); DCB, drug-coated balloon; NC, noncompliant balloon; NOA, new oral anticoagulant; TIMI, Thrombolysis in Myocardial Infarction.

Figure 1. Angiography of the patient treated with optical coherence tomography. Baseline coronary angiography imaging showing a thrombotic occlusion at left circumflex artery level (A) after predilatation with plaque modification balloons (B), and final clinical outcomes after drug-coated balloon implantation (C).

Figure 2. Optical coherence tomography imaging with angiographic co-registration after achieving flow. Yellow arrows are indicative of the process of neoatherosclerosis (restenotic heterogeneous plaque), the red arrow points at a red thrombus, and white stars are indicative of the stent struts.

Scientific evidence on the utility of DCB to treat STEACS due to very late stent thrombosis is scarce, only just a few isolated case reports.4 Since, conceptually, the DCB looks like an excellent therapeutic tool in this clinical setting, we believe trials with big enough samples and clinical and angiographic follow-up should be conducted to confirm or refute such hypothesis. We should mention the need for proper lesion preparation before using DCBs, and how important—actually mandatory—should be to use intracoronary imaging modalities (especially optical coherence tomography for its greater resolution capabilities) to clearly identify the pathogenic mechanisms involved. Therefore, the scarce use of such techniques in our series was our study main limitation.


None whatsoever.


All the authors were involved in the process of patient recruitment and manuscript revision. J. Valencia drafted the manuscript, conducted the clinical follow-up, and prepared the images.


None reported.


1. Adriaenssens T, Joner M, Godschalck TC, et al. Optical Coherence Tomography Findings in Patients With Coronary Stent Thrombosis. A Report of the PRESTIGE Consortium (Prevention of Late Stent Thrombosis by an Interdisciplinary Global European Effort). Circulation. 2017;136:1027-1031.

2. Jeger RV, Eccleshall S, Wan-Ahmad WA, et al. Drug-Coated Balloons for Coronary Artery Disease: Third Report of the International DCB Consensus Group. JACC Cardiovasc Interv. 2020;13:1391-1402.

3. Vos NS, Fagel ND, Amoroso G, et al. Paclitaxel-Coated Balloon Angioplasty Versus Drug-Eluting Stent in Acute Myocardial Infarction: The REVELATION Randomized Trial. JACC Cardiovasc Interv. 2019;12:1691-1699.

4. Alfonso F, Bastante T, Cuesta J, Benedicto A, Rivero F. Drug-Coated Balloon Treatment of Very Late Stent Thrombosis Due to Complicated Neoatherosclerosis. Arq Bras Cardiol. 2016;106:541-543.

* Corresponding author.

E-mail address: (J. Valencia).

Editor's page

Recic Uk 2304 F13

Original articles

Recic 23 014 Uk F1
Recic 23 021 Uk F1

Original articles

Recic 23 001 Uk F3
Recic 23 011 Uk F1


Scientific letters


Recic Uk 23 054 F1


Debate. Percutaneous revascularization in dilated cardiomyopathy

Recic 23 056 F1
Recic 23 058 F1

Impella-Clip: a secure and effective strategy in cardiogenic shock due to acute severe mitral regurgitation

Clara Ugueto-Rodrigo, Alfonso Jurado-Román, et al.

How would I approach it?
Isaac Pascual

Case resolution
Clara Ugueto-Rodrigo, Alfonso Jurado-Román, et al.

Cookies user preferences
We use cookies to ensure you to get the best experience on our website. If you decline the use of cookies, this website may not function as expected.
Accept all
Decline all
Read more
Tools used to analyze the data to measure the effectiveness of a website and to understand how it works.
Google Analytics