Risk Factors and Outcomes of Recurrent Drug-Eluting Stent Thrombosis: Insights From the REAL-ST Registry

Background: Stent thrombosis (ST) after drug-eluting stent (DES) implantation remains a life-threatening complication. Recurrent ST (RST) is not a rare phenomenon, potentially contributing to high mortality after the index ST events. However, little evidence is available about the incidence, risk factors, and clinical outcomes of definite RST after DES thrombosis. Methods and Results: From REAL-ST (Retrospective Multicenter Registry of ST After First- and Second- Generation DES Implantation), this study evaluated 595 patients with definite ST (first-generation DES thrombosis, n=314; second-generation DES thrombosis, n=281). During a median follow-up of 31 months, we identified 32 patients with definite RST after first-generation DES thrombosis (n=18) and second-generation DES thrombosis (n=15). Cumulative incidence of RST was 4.5% and 6.0% at 1 and 5 years, respectively, which did not significantly differ between first-generation DES thrombosis and second-generation DES thrombosis. Independent predictors of definite RST were early ST (hazard ratio [HR], 2.38; 95% CI, 1.06-5.35 [P=0.035]) and multivessel ST (HR, 3.47; 95% CI, 1.03-11.7 [P=0.044]). Definite RST was associated with a 2.8-fold increased risk of mortality (adjusted HR, 2.78; 95% CI, 1.35-5.73 [P=0.006]). Conclusions: Cumulative incidence of definite RST did not significantly differ between first-generation DES thrombosis and second-generation DES thrombosis. Early ST and multivessel ST were risk factors of definite RST. Definite RST significantly increased mortality after DES thrombosis, highlighting the clinical importance of preventing RST to improve outcomes of patients with ST. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: UMIN000025181.