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
© The Author(s). 2017
Received: 1 December 2016
Accepted: 30 March 2017
Published: 5 April 2017
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.
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.
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.
KeywordsMyocardial infarction Aspiration thrombectomy Intracoronary thrombolysis Coronary ectasia Case report
Intracoronary thrombosis in patients with ST-segment elevation myocardial infarction (STEMI) can cause distal embolization, no-reflow phenomena and stent thrombosis, and increase the risk of adverse cardiac events and death following primary percutaneous coronary interventions (PCIs) [1, 2]. Although the beneficial effect of manual aspiration thrombectomy (MAT) during primary PCIs is still open to debate, it is frequently employed as a first-line therapy to reduce these adverse events . However, there are no other effective options when MAT delivers insufficient coronary blood flow, especially in patients with large thrombus burdens. Here we report a case of successful coronary reperfusion through a combination of catheter-directed intracoronary thrombolysis and MAT in STEMI caused by thrombotic occlusion of an ectatic coronary artery.
Intravenous infusion of the glycoprotein IIb/IIIa inhibitor was maintained for 12 h after PCI. Oral administration of aspirin (100 mg/day), ticagrelor (180 mg/day), rosuvastatin (20 mg/day), bisoprolol (1.25 mg/day), and candesartan (8 mg/day) was continued. Low molecular weight heparin (dalteparin 100 IU/kg every 12 h; Fragmin®, Pfizer Inc., New York, NY) was administered subcutaneously after the femoral sheath was removed. No significant bleeding complications occurred after PCI. CAG repeated 9 days after the PCI revealed TIMI grade 3 blood flow in the RCA and PDA, and insignificant focal stenosis with a small amount of remaining thrombus in the lesion (Fig. 2e). IVUS showed that the MLA was 9.7 mm2 in the lesion (Fig. 3d) and the fractional flow reserve measured under maximal hyperemia was 0.98. Based on these assessments, we decided not to perform any additional intervention. The patient was discharged 12 days after PCI. CAG repeated 6 months after PCI showed complete dissolution of the thrombi and minimal remaining stenosis in the lesion with TIMI 3 blood flow in the RCA (Fig. 2f).
Discussion and conclusions
Massive intracoronary thrombi are associated with unsuccessful angiographic reperfusion and unfavorable clinical outcomes [1, 4]. Unresolved intracoronary thrombi can cause microvascular obstruction, known as the no-reflow phenomenon, and result in reduced myocardial perfusion at the microvascular level, increased infarct size and higher mortality . Although there have been improvements in antiplatelet and anticoagulant regimens and technical advances in PCIs, intracoronary thrombus remains one of the most dreaded enemies of interventional cardiologists. MAT is one of the most frequently used thrombectomy methods in primary PCIs, because the procedure is simple and the risk of vascular injury and distal embolism is low. Clinical guidelines also suggest that MAT is a reasonable approach when intracoronary thrombi are encountered . However, studies have yielded inconsistent results in terms of its benefits in primary PCI [6–8]. The TASTE trial showed no benefits of MAT for mortality, re-hospitalization and stent thrombosis . More recently, Jolly et al.  also reported that MAT did not reduce cardiovascular events, whereas it increased stroke rate. This result may partly be related to insufficient thrombus removal and inadequate coronary blood flow recovery in cases with massive intracoronary thrombosis. Safe and feasible alternative strategies are needed when MAT fails during primary PCI.
Before coronary stents were much used, intracoronary thrombolysis was used in patients with all types of coronary artery disease [9, 10]. However, because studies gave discouraging results  and primary PCI with stent implantation became routine, intracoronary thrombolysis was rarely used in clinical practice. In recent years, intracoronary thrombolysis has regained popularity as an adjuvant therapy for primary PCI, as studies using different thrombolytic agents and improved antiplatelet regimens showed it to be safe and effective. Kelly et al.  reported that intracoronary infusion of tenecteplase was safe and effective for coronary flow recovery in patients with myocardial infarction. More recently, Boscarelli et al.  found that adjuvant intracoronary infusion of low dose tenecteplase and alteplase in STEMI significantly reduced the thrombi remaining after MAT and improved coronary blood flow. Several case reports of massive intracoronary thrombosis also described successful recovery of coronary blood flow after intracoronary thrombolysis using alteplase  and tenecteplase .
We used the glycoprotein IIb/IIIa inhibitor after intracoronary thrombolysis, which may significantly increase the risk of major bleeding events. However, the thrombolytic agent doses used through intracoronary routes are usually much lower than those used through intravenous routes. Kelly et al.  also reported that only 1 case of major bleeding (2.9%) among 34 patients after intracoronary thrombolysis using tenectaplase, which is similar to the major bleeding rates reported regularly in acute coronary syndrome . Moreover, the majority of the patients (76%) in their study received glycoprotein IIb/IIIa inhibitors simultaneously with intracoronary thrombolysis.
In our case, a massive thrombotic occlusion occurred in the ectatic RCA. Coronary ectasia is defined as a diffuse dilation of a coronary artery to a diameter at least 1.5 times larger than normal coronary artery diameter . It is present in 1–5% of patients undergoing CAG . Various reperfusion strategies including MAT alone, simple balloon angioplasty, pulse-spray thrombolysis, intracoronary thrombolysis and mesh-covered stent implantation have been proposed in STEMI in ectatic coronary arteries [19–21]. Several randomized controlled trials have reported that rheolytic thrombectomy was more effective than MAT in thrombus removal and myocardial reperfusion in patients with STEMI, although there were no differences in infarct sizes and adverse cardiac events following PCI between rheolytic thrombolysis and MAT [22, 23]. Simple balloon angioplasty might increase the risk of distal embolization after intracoronary thrombus is incompletely removed. Prolonged intravenous heparin infusion is a viable option for the remaining thrombus after MAT in ectatic coronary arteries . However, for ectatic coronary arteries, because the sheer amount of thrombus is massive and blood flow is slow, no single strategy would be sufficient. In fact, we employed multiple strategies namely MAT, balloon angioplasty and intracoronary thrombolysis during the PCI to achieve a good immediate result. We think that the additional anatomical and physiological information obtained by IVUS and by measuring the fractional flow reserve helped us avoid stent implantation, which could have led to incomplete stent apposition. Self-expendable stents have been introduced for patients with complex coronary anatomy including aneurysmal dilation, which may also be an alternative strategy to avoid difficulty in stent apposition, as shown in our case .
In conclusion, catheter-directed intracoronary thrombolysis may be a safe and effective alternative reperfusion strategy that may be selected when MAT alone fails to achieve sufficient coronary blood flow in the culprit vessel in STEMI associated with massive thrombosis in ectatic coronary arteries.
Minimal lumen area
Primary percutaneous coronary intervention
Posterior descending artery
Right coronary artery
ST-elevation myocardial infarction
Thrombolysis in myocardial infarction
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JHS drafted the manuscript and performed the angioplasty. EK drafted the manuscript and edited the figures. BKK and YL critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
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