Precision Management of Coronary Stent Thrombosis: A Contemporary Guide

Purpose of Review: Stent thrombosis (ST) is an uncommon but serious complication of percutaneous coronary intervention (PCI), associated with high morbidity, mortality, and a substantial risk of recurrence. Although its incidence has declined with contemporary drug-eluting stents (DES), outcomes remain poor. This review aims to summarize contemporary evidence on ST, including mechanism, risk factors, and management strategies to improve PCI outcomes. Recent Findings: The risk of ST is multifactorial, influenced by patient comorbidities, lesion characteristics, procedural technique, and device-related factors. Timing after the index procedure reflects distinct mechanisms: early ST is often driven by procedural factors such as underexpansion, malapposition, or edge dissection, together with premature discontinuation of dual antiplatelet therapy (DAPT). Optical coherence tomography (OCT) studies consistently demonstrate uncovered struts, malapposition, and underexpansion as major contributors. In contrast, late and very late ST are more commonly related to impaired vessel healing, delayed endothelialization, late-acquired malapposition from vascular remodeling, and neoatherosclerosis leading to in-stent plaque rupture. Management is based largely on expert consensus, as no randomized trials have directly addressed this complication. Balloon angioplasty remains an effective option, particularly when underexpansion or malapposition are present, while additional stent implantation should generally be avoided unless needed for edge dissection or neoatherosclerosis. Summary: Intracoronary imaging is strongly recommended, as angiography alone cannot reliably assess stent-related pathology, and imaging-guided PCI has been shown to lower ST risk. Premature cessation of DAPT, especially within the first month, is one of the strongest predictors, although many events still occur despite ongoing therapy. Future studies should focus on personalized risk prediction, further refinement of DES to reduce late complications, and long-term, mechanism-based studies to guide prevention and treatment.