Incidence of Stent Occlusion in LAD with Three Stents
When three stents are placed in the LAD, observational data suggest a significantly elevated risk of stent thrombosis and restenosis, though precise incidence rates are not well-defined in the literature—the ESC guidelines emphasize that DAPT should never be interrupted in these patients and surgical revascularization should be strongly considered instead of sequential stenting. 1
Key Clinical Evidence on Multiple Overlapping Stents
Acute and Mid-Term Outcomes
In-hospital complications occur in approximately 16.6% of patients receiving multiple overlapping drug-eluting stents (average 2.8 stents, mean length 80mm) in the LAD, primarily manifesting as non-Q-wave myocardial infarction. 2
Intraprocedural stent thrombosis occurred in 1.5% of cases (1 out of 66 patients) during the index procedure when multiple overlapping DES were placed in diffuse LAD disease. 2
At six-month follow-up, the hierarchical major adverse cardiac event rate was 15%, with target vessel revascularization required in 15% of patients treated with multiple overlapping stents in the LAD. 2
Critical Risk Factors with Multiple Stent Layers
The ESC guidelines explicitly state that having three stent layers in a single coronary lesion creates a high-risk scenario where DAPT interruption should never occur, even remotely from the intervention. 1 This recommendation stems from observational data suggesting substantially elevated thrombotic risk with multiple overlapping stents.
- The need to sequentially stent one coronary lesion three times should prompt serious consideration of switching from PCI to CABG to obtain long-lasting vessel patency, particularly when the LAD is involved. 1
Comparison to Standard Single-Stent Outcomes
Proximal LAD Stenting (Single Stent)
Restenosis rates with single bare-metal stents in ostial LAD lesions are approximately 26.1% at six months, with target lesion revascularization rates of 11.7%. 3
Drug-eluting stents in the proximal LAD demonstrate superior outcomes compared to bare-metal stents, with hazard ratios of 0.39 for restenosis and 0.58 for mortality. 4
Stent thrombosis risk is higher in the proximal LAD compared to the left circumflex (HR 2.32, CI 1.11-4.85), though no difference exists compared to the RCA. 4
Critical Management Implications
Mandatory DAPT Duration
Patients with three overlapping stents in the LAD require prolonged or even lifelong DAPT if tolerated, as the risk of stent thrombosis remains substantially elevated. 1
After a first stent thrombosis event, the long-term risk of recurrent thrombosis is high, reinforcing the need for indefinite DAPT continuation. 1
Very late stent thrombosis can occur 20 months or more after implantation, even with newer-generation DES, particularly after DAPT discontinuation. 1
Surgical Revascularization Consideration
The requirement for three sequential stents in a single LAD lesion should trigger Heart Team discussion favoring CABG over continued PCI, especially given the LAD's critical territory and the compromised long-term patency with multiple stent layers. 1
- Proximal LAD stenosis with complex anatomy is a Class I indication for considering CABG, which provides superior long-term vessel patency compared to multiple overlapping stents. 5
Common Clinical Pitfalls
Premature DAPT Discontinuation
Complete interruption of DAPT (discontinuation of both antiplatelet agents) is an independent predictor of stent thrombosis and mortality, particularly catastrophic in patients with multiple overlapping stents. 1, 6
- Even for procedures requiring antiplatelet interruption, at least one agent (preferably aspirin) should be maintained if hemodynamically tolerable. 6
Underestimating Thrombotic Risk
The presence of three stent layers creates a uniquely high-risk substrate where standard risk stratification tools may underestimate true thrombotic risk. 1
- Stent underexpansion or undersizing frequently contributes to stent thrombosis and should be assessed with imaging guidance (OCT or IVUS) when multiple stents are placed. 1
Failure to Consider Alternative Revascularization
Sequential stenting attempts that result in three stent layers represent a failure point where surgical revascularization should have been considered earlier to avoid the compounded risks of multiple metal layers. 1