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A case of successful reperfusion through a combination of intracoronary thrombolysis and aspiration thrombectomy in ST-segment elevation myocardial infarction associated with an ectatic coronary artery

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ABSTRACT

Background: Large thrombus burdens in ectatic coronary arteries that remain after aspiration thrombectomy can negatively impact outcomes following percutaneous coronary interventions in patients with acute myocardial infarction.

Case presentation: A 53-year-old man presented with ST-segment elevation myocardial infarction (STEMI). Coronary angiography revealed an ectatic right coronary artery (RCA) that was completely occluded in the mid portion by a large amount of thrombus. Catheter-directed intracoronary thrombolysis with alteplase led to recovery of coronary blood flow, which multiple attempts of aspiration thrombectomy had failed to achieve. Coronary angiography 9 days later showed good blood flow and insignificant stenosis remaining in the RCA; this had completely resolved in 6 months’ follow-up coronary angiography.

Conclusion: Catheter-directed intracoronary thrombolysis can be performed effectively and safely when repeat aspiration thrombectomy fails to produce satisfactory coronary reperfusion in STEMI patients with large thrombus burdens in ectatic coronary arteries.

No MeSH data available.


Related in: MedlinePlus

Coronary angiography. a Thrombotic total occlusion of the mid portion of the right coronary artery (RCA) with TIMI grade 0 flow. b After thrombus aspiration, a large filling defect remained due to extensive thrombus in the mid portion of the RCA with distal embolization in the posterior descending artery (PDA). c After initial intracoronary thrombolysis and repeated thrombus aspiration, improvement of TIMI flow, distal embolization, and residual thrombus at the mid portion of the RCA were noted. d After balloon angioplasty and second intracoronary thrombolysis, the culprit stenotic lesion was dilated, but TIMI flow worsened with distal embolization. e On the ninth day after the primary percutaneous intervention, TIMI flow was restored, but focal eccentric intermediate stenosis with some residual thrombus remained at the mid portion of the RCA. f Six months after discharge, marked dissolution of the thrombus and only minimal stenosis at the mid portion of the RCA was noted
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Fig2: Coronary angiography. a Thrombotic total occlusion of the mid portion of the right coronary artery (RCA) with TIMI grade 0 flow. b After thrombus aspiration, a large filling defect remained due to extensive thrombus in the mid portion of the RCA with distal embolization in the posterior descending artery (PDA). c After initial intracoronary thrombolysis and repeated thrombus aspiration, improvement of TIMI flow, distal embolization, and residual thrombus at the mid portion of the RCA were noted. d After balloon angioplasty and second intracoronary thrombolysis, the culprit stenotic lesion was dilated, but TIMI flow worsened with distal embolization. e On the ninth day after the primary percutaneous intervention, TIMI flow was restored, but focal eccentric intermediate stenosis with some residual thrombus remained at the mid portion of the RCA. f Six months after discharge, marked dissolution of the thrombus and only minimal stenosis at the mid portion of the RCA was noted

Mentions: A 53-year-old man presented in the emergency department with sudden chest pain lasting for 30 min. He was a 40-pack-year current smoker with high blood pressure on no medication. Blood pressure was 160/110 mmHg and pulse rate 60 beats/min. Electrocardiography showed ST-segment elevations in leads II, III, and aVF (Fig. 1a). Serum creatinine was 0.8 mg/dl and serum troponin I 0.01 ng/ml. Killip classification was class I. Aspirin 300 mg and ticagrelor 180 mg were administered, and coronary angiography (CAG) was performed immediately under temporary ventricular pacing. CAG revealed an ectatic right coronary artery (RCA) completely occluded by a large amount of thrombus in the mid-portion (Fig. 2a). A bolus of unfractionated heparin (8000 IU) and glycoprotein IIb/IIIa antagonist (abciximab, 0.25 mg/kg) was administered intravenously and MAT was performed three times using a 6-Fr aspiration catheter (Rebirth, Goodman Co. Ltd., Nagoya, Japan). After red thrombi were aspirated, thrombolysis in myocardial infarction (TIMI) grade 2 flow was achieved but a large filling defect persisted in the mid portion of the RCA, with distal embolization in the posterior descending artery (PDA) (Fig. 2b). Intravascular ultrasound (IVUS) (Atlantis, Boston Scientific, Natick, MA) revealed a ruptured plaque containing a large necrotic core and a large amount of thrombus remaining in the lesion. The external elastic membrane (EEM) diameter and the luminal diameter of the normal adjacent proximal segment of the occlusion were 7.5 mm and 6.5 mm, respectively (Fig. 3a). The culprit lesion was 7.7 mm in EEM diameter and 4.8 mm2 in minimal luminal area (MLA) (Fig. 3b). Because stent apposition might be difficult in such a large vessel, we decided to perform catheter-directed intracoronary thrombolysis using alteplase. The tip of a 2.7 Fr microcatheter (Progreat®, Terumo, Somerset, NJ, USA) was placed on the culprit lesion, and 5 mg of alteplase (Actilyse, Boehringer Ingelheim, Germany) in 5 mL normal saline was slowly administered over five minutes through the microcatheter. After 10 min, CAG showed improved coronary blood flow from the TIMI grade 2 to 3 in the mid portion of the RCA and from the TIMI grade 0 to 1 in the PDA, with remaining thrombi in the mid portion (Fig. 2c). Because significant stenosis persisted, a 4.5 × 8 mm non-compliant balloon (Quantum, Boston Scientific, Natick, MA) was inflated up to 16 atm in the mid portion of the RCA to disrupt the partially lysed thrombi. The lesion was dilated after the balloon angioplasty; however TIMI flow of the RCA appeared to be worsened (Fig. 2d). Intracoronary thrombolysis was repeated in the same manner. Blood flow improved to TIMI grade 3 and IVUS showed increased MLA with remaining thrombi (Fig. 3c). The chest pain was completely relieved and the ST-segment elevation was resolved (Fig. 1b).Fig. 1


A case of successful reperfusion through a combination of intracoronary thrombolysis and aspiration thrombectomy in ST-segment elevation myocardial infarction associated with an ectatic coronary artery
Coronary angiography. a Thrombotic total occlusion of the mid portion of the right coronary artery (RCA) with TIMI grade 0 flow. b After thrombus aspiration, a large filling defect remained due to extensive thrombus in the mid portion of the RCA with distal embolization in the posterior descending artery (PDA). c After initial intracoronary thrombolysis and repeated thrombus aspiration, improvement of TIMI flow, distal embolization, and residual thrombus at the mid portion of the RCA were noted. d After balloon angioplasty and second intracoronary thrombolysis, the culprit stenotic lesion was dilated, but TIMI flow worsened with distal embolization. e On the ninth day after the primary percutaneous intervention, TIMI flow was restored, but focal eccentric intermediate stenosis with some residual thrombus remained at the mid portion of the RCA. f Six months after discharge, marked dissolution of the thrombus and only minimal stenosis at the mid portion of the RCA was noted
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Fig2: Coronary angiography. a Thrombotic total occlusion of the mid portion of the right coronary artery (RCA) with TIMI grade 0 flow. b After thrombus aspiration, a large filling defect remained due to extensive thrombus in the mid portion of the RCA with distal embolization in the posterior descending artery (PDA). c After initial intracoronary thrombolysis and repeated thrombus aspiration, improvement of TIMI flow, distal embolization, and residual thrombus at the mid portion of the RCA were noted. d After balloon angioplasty and second intracoronary thrombolysis, the culprit stenotic lesion was dilated, but TIMI flow worsened with distal embolization. e On the ninth day after the primary percutaneous intervention, TIMI flow was restored, but focal eccentric intermediate stenosis with some residual thrombus remained at the mid portion of the RCA. f Six months after discharge, marked dissolution of the thrombus and only minimal stenosis at the mid portion of the RCA was noted
Mentions: A 53-year-old man presented in the emergency department with sudden chest pain lasting for 30 min. He was a 40-pack-year current smoker with high blood pressure on no medication. Blood pressure was 160/110 mmHg and pulse rate 60 beats/min. Electrocardiography showed ST-segment elevations in leads II, III, and aVF (Fig. 1a). Serum creatinine was 0.8 mg/dl and serum troponin I 0.01 ng/ml. Killip classification was class I. Aspirin 300 mg and ticagrelor 180 mg were administered, and coronary angiography (CAG) was performed immediately under temporary ventricular pacing. CAG revealed an ectatic right coronary artery (RCA) completely occluded by a large amount of thrombus in the mid-portion (Fig. 2a). A bolus of unfractionated heparin (8000 IU) and glycoprotein IIb/IIIa antagonist (abciximab, 0.25 mg/kg) was administered intravenously and MAT was performed three times using a 6-Fr aspiration catheter (Rebirth, Goodman Co. Ltd., Nagoya, Japan). After red thrombi were aspirated, thrombolysis in myocardial infarction (TIMI) grade 2 flow was achieved but a large filling defect persisted in the mid portion of the RCA, with distal embolization in the posterior descending artery (PDA) (Fig. 2b). Intravascular ultrasound (IVUS) (Atlantis, Boston Scientific, Natick, MA) revealed a ruptured plaque containing a large necrotic core and a large amount of thrombus remaining in the lesion. The external elastic membrane (EEM) diameter and the luminal diameter of the normal adjacent proximal segment of the occlusion were 7.5 mm and 6.5 mm, respectively (Fig. 3a). The culprit lesion was 7.7 mm in EEM diameter and 4.8 mm2 in minimal luminal area (MLA) (Fig. 3b). Because stent apposition might be difficult in such a large vessel, we decided to perform catheter-directed intracoronary thrombolysis using alteplase. The tip of a 2.7 Fr microcatheter (Progreat®, Terumo, Somerset, NJ, USA) was placed on the culprit lesion, and 5 mg of alteplase (Actilyse, Boehringer Ingelheim, Germany) in 5 mL normal saline was slowly administered over five minutes through the microcatheter. After 10 min, CAG showed improved coronary blood flow from the TIMI grade 2 to 3 in the mid portion of the RCA and from the TIMI grade 0 to 1 in the PDA, with remaining thrombi in the mid portion (Fig. 2c). Because significant stenosis persisted, a 4.5 × 8 mm non-compliant balloon (Quantum, Boston Scientific, Natick, MA) was inflated up to 16 atm in the mid portion of the RCA to disrupt the partially lysed thrombi. The lesion was dilated after the balloon angioplasty; however TIMI flow of the RCA appeared to be worsened (Fig. 2d). Intracoronary thrombolysis was repeated in the same manner. Blood flow improved to TIMI grade 3 and IVUS showed increased MLA with remaining thrombi (Fig. 3c). The chest pain was completely relieved and the ST-segment elevation was resolved (Fig. 1b).Fig. 1

View Article: PubMed Central - PubMed

ABSTRACT

Background: Large thrombus burdens in ectatic coronary arteries that remain after aspiration thrombectomy can negatively impact outcomes following percutaneous coronary interventions in patients with acute myocardial infarction.

Case presentation: A 53-year-old man presented with ST-segment elevation myocardial infarction (STEMI). Coronary angiography revealed an ectatic right coronary artery (RCA) that was completely occluded in the mid portion by a large amount of thrombus. Catheter-directed intracoronary thrombolysis with alteplase led to recovery of coronary blood flow, which multiple attempts of aspiration thrombectomy had failed to achieve. Coronary angiography 9 days later showed good blood flow and insignificant stenosis remaining in the RCA; this had completely resolved in 6 months’ follow-up coronary angiography.

Conclusion: Catheter-directed intracoronary thrombolysis can be performed effectively and safely when repeat aspiration thrombectomy fails to produce satisfactory coronary reperfusion in STEMI patients with large thrombus burdens in ectatic coronary arteries.

No MeSH data available.


Related in: MedlinePlus