Case Report

Distal coronary macroemboli and thrombus aspiration in a patient with acute myocardial infarction

Abstract

Primary percutaneous coronary intervention is an effective strategy in the opening of infarct-related artery in ST-segment elevation myocardial infarction . However, macro- and microembolization during PCI in STEMI is frequent and may induce microvascular obstruc- tion (Thromb Haemost. 2006;96:700-710; Catheter Cardio- vasc Interv. 2008;71:863-869; Circulation. 2009;119: 1311-1319). Distal macroembolization of atheromatous and thrombotic debris can be detected by angiography in up to 15% of patients undergoing Primary PCI (Eur Heart J. 2002;23:1112-1117). Several clinical trials have shown that the presence and size of culprit thrombus is the most powerful predictor of the impaired coronary flow and an independent predictor of adverse outcomes (J Am Coll Cardiol. 2007;50:573-583; Chest. 2002;122:1322-1332).

Mounting interest has also emerged regarding the role of distal embolization as a major determinant of infarct size and impaired myocardial perfusion after PCI (Thromb Haemost. 2006;96:700-710; Catheter Cardiovasc Interv. 2008;71:863-869; Circulation. 2009;119:1311-1319).

Therefore, Mechanical thrombectomy devices have been proposed to remove thrombi from coronary arteries and also decrease the likelihood of distal embolization during subsequent angioplasty and stent deployment. However, embolization may occur predominantly at the time of the insertion of guidewire or initial balloon or stent inflation. Herein, we report the case of a 54-year-old woman presenting with inferior STEMI because of the proximal occlusion of right coronary artery. Because of the development of distal coronary macroembolization after balloon angioplasty, we performed successful thrombus aspiration and subsequent right coronary artery stenting.

A 54-year-old woman presented to the emergency department (ED) with history of sudden onset, squeezing chest pain lasting 3 hours. She had no history of note but was a smoker. A physical examination revealed a blood pressure of 110/60 mm Hg and a regular heart rate of 72 beats per

minute. Her initial physical examination was normal. The electrocardiogram taken in the ED showed the ST-segment elevation on inferior leads. Initial laboratory results were notable for hemoglobin 15.6 g/dL, hematocrit 44.2%, leukocyte count 11.200/L, platelet count 191.000/L, Serum glucose 146 mg/dL, creatinine 0.85 mg/dL, and C-reactive protein 18.2 (upper limit, 3.0 mg/L). Levels of creatine kinase-MB isoenzyme and troponin T were 15.0 U/L (upper limit, 25.0 U/L) and 0.01 ug/L (upper limit, 0.01 ug/L), respectively. The patient was hospitalized with a diagnosis of inferior ST-segment elevation myocardial infarction and loaded with 300 mg of both acetylsalicylic acid and clopidogrel before transfer to the catheterization room for primary PCI.

The coronary angiography revealed total occlusion of proximal right coronary artery (Fig. 1A), and normal left anterior descending and circumflex coronary artery. A 0.014-in floppy guidewire was passed through the lesion to the distal right coronary artery. Because of the presence of TIMI 0 coronary flow, 2.0 x 15-mm balloon angioplasty was performed initially (Fig. 1B). After balloon angioplasty, distal coronary macroemboli was developed while we were taking coronary angiogram (Fig. 1C-E). Therefore, tirofiban bolus was started immediately and then we decided to perform thrombus aspiration for distal macroembolization because of the higher Thrombus burden and impaired distal coronary circulation (Fig. 1F). After positioning of guidewire from thrombus to distal right coronary artery, DIVER thrombus aspiration catheter was used to suction of distal coronary macroemboli (Fig. 2A). After successful retrieval of distal coronary thrombus, right coronary artery flow was recovered (Fig. 2B). After then, 3.0 x 13 mm bare-metal stent was deployed to the proximal right coronary artery lesion (Fig. 2C and D). Final coronary angiography revealed no residual stenosis of right coronary artery with TIMI III flow (Fig. 2E and F). After successful thrombus aspiration and subsequent stent deployment of right coronary artery, chest pain and ST elevation on inferior leads were prominently diminished. The patient became stable during follow-up. She was discharged 3 days later with a prescription anti-ischemic and Dual antiplatelet therapy.

Thrombus aspiration is a popular technique for removing thrombi from coronary arteries, especially in acute coronary syndromes [1-3]. It has been shown that culprit lesions with higher thrombus burden and flow impairment are associated

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Fig. 1 A, Angiographic view of the occluded right coronary artery. B, Angiographic view of the insertion of 0.014-in floppy guidewire and coronary angioplasty with 2.0 x 15-mm coronary balloon. C-E, The angiographic demonstration of the development of distal coronary macroemboli and the distal occlusion of the right coronary artery. Black arrows indicate coronary macroemboli. F, The angiographic view of the development of the no-reflow of right coronary artery.

with a greater device induced thrombus score reduction and flow improvement [4-6]. In our case report, these provide us a rationale for thrombus aspiration because of the development of distal coronary macroemboli and impair- ment of coronary circulation during primary PCI [7-9]. However, the effect of adjunctive devices over clinical

outcomes is not clearly defined in patients presenting with STEMI. Therapeutic benefits of such devices have been examined in numerous Prospective trials and meta-analyses [10-16]. The results of these trials and meta-analyses have been conflicting. The recently published Thrombus Aspira- tion During Percutaneous Coronary Intervention in Acute

Fig. 2 A, The insertion of the thrombus aspiration catheter. Black arrow indicates the tip marker of the thrombus aspiration catheter. B, The angiographic appearance of the resolution of impaired coronary circulation after successful thrombus aspiration. C, D, The angiographic view of the insertion and the deployment of 3.0 x 13-mm coronary stent. E and F, Final good coronary visualization with TIMI III coronary flow after thrombus aspiration and stent deployment of right coronary artery in the cranial-right anterior oblique and anteroposterior cranial angiogram.

Myocardial Infarction Study, the largest randomized study of a thrombectomy device published to date, has refocused the interest in this area [15]. The results of this trial demonstrated that thrombus aspiration therapy during primary PCI

improved surrogate end points, and also short- and long- term Clinical end points [15,16].

Although there is no routine use of thrombus aspiration devices for the treatment of STEMI patients, patient selection

and careful procedural timing are likely to improve outcomes in patients undergoing thrombus aspiration therapy. Also, the clinical characteristics of STEMI patients who can modulate the treatment benefits of thrombectomy devices are not fully understood. Therefore, pending the results of additional large-scale studies with long-term follow-up data, treatment of these patients must be individualized, as done in our case.

In conclusion, despite the relevant advancement made in the field of adjuvant medical therapy and PCI technique, distal embolization is frequent and may result in obstruction of the coronary flow with subsequent reduction in efficacy of reperfusion. Considering the results of the Thrombus Aspiration During Percutaneous Coronary Intervention in Acute Myocardial Infarction Study [15,16] and recent meta-analyses [13,14], the use of thrombus aspiration therapy of infarct-related artery might have important role in improving myocardial perfusion and clinical outcomes after PCI for STEMI. To date, although there is no routine use of thrombus aspiration for the treatment of STEMI patients, it should be kept in mind that benefits of thrombus aspiration therapy might depend on patient selection and careful procedural timing. Additional large-scale studies with long- term follow-up data will clarify this issue.

Sadik Acikel MD Ekrem Yeter MD Harun Kilic MD Ramazan Akdemir MD

Department of Cardiology Ministry of Health Diskapi Yildirim Beyazit Research and

Educational Hospital 06110 Ankara, Turkey

E-mail address: [email protected] doi:10.1016/j.ajem.2009.09.012

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