CathLabHub

CathLabHub complications toolkitcathlabhub.com/toolkit/acute-closure-stent-thrombosisIn review, October 24, 2026

Recognize

The signs on the monitor, the image and the patient.

  • ImageLoss of flow, a new filling defect inside or within 5 mm of the stent, or a haze at the edge 12.
  • MonitorNew ST elevation, ventricular arrhythmia or hypotension 2.
  • PatientChest pain returns in a vessel already treated.
  • LabA low ACT, a missed P2Y12 load, or heparin that did not reach the vein 2.

Act now

In the order the operator does them. The first three come first, whatever else is happening.

  1. Keep the wire across; losing it can turn a fixable problem into a catastrophe 2.
  2. Check the ACT now and give more heparin if it is low 2.
  3. Call for help; support the pressure and treat arrhythmias.
  4. Separate dissection (needs a stent) from embolization (worse with a stent) with angiography and IVUS or OCT 2.
  5. Thrombus: a glycoprotein IIb/IIIa inhibitor or cangrelor, aspiration, then balloon 2.
  6. Fix the mechanical cause that made the stent clot: underexpansion, edge dissection, inflow or outflow disease 2.
  7. Spasm: intracoronary nitroglycerin 100 to 300 mcg, repeated, or a calcium channel blocker 2.
  8. Hemodynamic support if a large territory is closing 2.

Equipment

From the complications cart. Linked items open in the equipment directory.

Drugs

Adult doses as the cited source gives them. Check your formulary and the label.

Who to call

The escalation ladder, first call first.

  1. Second operator: to hold the wire and run imaging.
  2. Shock team: if the pressure falls with a large territory at risk 2.
  3. Cardiac surgery: if the vessel cannot be reopened and the territory is large 2.
  4. Hematology or pharmacy: if heparin resistance or HIT is suspected 2.

The bailout step by step

Stent thrombosis in the lab, step by step 21

  1. Keep the wire; recheck and correct the ACT.
  2. Start a glycoprotein IIb/IIIa inhibitor or cangrelor.
  3. Aspirate along the stent with an aspiration catheter until flow returns or no more thrombus comes back.
  4. Balloon the stent with a noncompliant balloon sized to the reference.
  5. Image with IVUS or OCT: expansion, apposition, edge dissection, residual thrombus.
  6. Correct what you find: post dilate an underexpanded stent, stent an edge dissection.
  7. Final angiogram: TIMI flow, no residual filling defect.

Prevent

  • Therapeutic ACT throughout, checked at intervals 2.
  • A P2Y12 inhibitor before PCI, ideally pretreatment when planned 2.
  • Prepare the lesion and confirm stent expansion with imaging 2.
  • Aspirate and flush the sheath before inserting catheters 2.

After care and documentation

  • Do not interrupt dual antiplatelet therapy; premature discontinuation is the strongest risk factor 1.
  • Classify stent thrombosis by the Academic Research Consortium definitions (definite, probable, possible) and timing 1.
  • Document the ACT values, the antiplatelet loading times and the mechanism found on imaging.

Practice

Emergency simulator cases in the Cath Trainer app. The link opens Cases; type the case number in the search box.

  • EMG-0018: Pain returns in a vessel already stented
  • EMG-0068: New ST elevation during a long PCI

References

  1. Berg R, Lim MJ. Complications of percutaneous coronary interventions. In: Kern MJ, ed. The Interventional Cardiac Catheterization Handbook. 3rd ed. Saunders, Elsevier; 2013. Chapter 4.
  2. Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 25, Acute vessel closure.
  3. Kengreal (cangrelor) for injection, US prescribing information. Chiesi USA.
  4. Aggrastat (tirofiban hydrochloride) injection, US prescribing information. Medicure.
  5. Brilakis ES. Manual of Percutaneous Coronary Interventions: A Step-by-Step Approach. Academic Press, Elsevier; 2021. Chapter 3, Medications.
  6. CathLabHub Cath Trainer app, emergency simulator: case library (cathlabhub.com/app, Cases).

Educational reference for cath lab teams, not medical advice and not a standard of care. Your local policy, the device instructions for use and current guidelines govern. Verify every dose before use. Printed from cathlabhub.com/toolkit/acute-closure-stent-thrombosis. First version, in clinical review: an interventional cardiologist is checking every card before it is final. Every number cites its source on the card.