Early Multivessel Stent Thrombosis Causing Rapid Progression From Non-ST-Segment Elevation Myocardial Infarction (NSTEMI) to ST-Segment Elevation Myocardial Infarction (STEMI) Requiring Mechanical Circulatory Support

Early stent thrombosis is an uncommon but life-threatening complication of percutaneous coronary intervention (PCI), associated with high mortality despite adherence to dual antiplatelet therapy (DAPT). Early stent thrombosis is a rare but serious complication of percutaneous coronary intervention that is often associated with significant morbidity and mortality. Multifactorial contributors, including diabetes mellitus and reduced left ventricular ejection fraction, significantly increase the risk. We present the case of a 50-year-old African American male with no prior medical history, presenting with persistent chest pain, nausea, vomiting, and diaphoresis. Initial workup revealed elevated troponins, and coronary angiography identified critical stenoses in the left anterior descending (LAD) and obtuse marginal (OM) arteries, which were treated with PCI with drug-eluting stents followed by DAPT. Further investigation revealed new-onset heart failure, diabetes, and hypercholesterolemia, prompting initiation of guideline-directed medical therapy (GDMT), insulin, and atorvastatin, respectively. The patient was discharged but returned within 24 hours with the new onset of chest pain. Emergency coronary angiography demonstrated occlusion of the proximal LAD at the stented segment as well as thrombotic occlusion involving the circumflex/OM stent, consistent with early stent thrombosis. Intravascular ultrasound (IVUS) performed during the repeat intervention demonstrated a relatively large reference vessel diameter of approximately 4.5 mm with areas of suboptimal stent expansion that may have contributed to thrombus formation. IVUS-guided repeat PCI was performed with high-pressure balloon post-dilation and additional stent optimization to restore thrombolysis in myocardial infarction grade 3 (TIMI-3) flow. Due to significant hemodynamic compromise with elevated left ventricular end-diastolic pressure (LVEDP) of 40 mmHg and hypoxia requiring non-invasive ventilatory support, mechanical circulatory support with an Impella CP® device was initiated. Following stabilization, the Impella CP® device was removed, GDMT was resumed, blood glucose was optimized, and the patient was discharged home on DAPT after successful management and cardiology clearance with the instruction for close follow-up with cardiology and the primary care physician. This case underscores the complex interplay of patient-related and procedural factors in early stent thrombosis and highlights the critical role of individualized pharmacotherapy, meticulous stent optimization with intravascular imaging, and timely mechanical support in achieving favorable outcomes in high-risk patients.