The Use of an XMI-Rapid Exchange Rheolytic Thrombectomy Catheter During an Acute Myocardial Infarction Secondary to Thrombus Bur

Overview of AngioJet Rheolytic Thrombectomy System Another mode of treatment for acute myocardial infarction is the AngioJet® Rheolytic Thrombectomy System (Possis Medical, Inc., Minneapolis, MN). AngioJet is a thrombectomy catheter used to extract or remove clot (thrombus burden) from within the coronary artery. The catheter is a 135 cm, 4.0 French, sterile, single-use catheter designed and approved for removing thrombus from coronary arteries. High velocity saline jets directed back into the catheter create a localized low-pressure zone at the distal tip (Bernoulli effect) which results in the evacuation breakup, and removal of thrombus through the exhaust lumen. The Catheter is designed to track over a 0.014- guide wire and through a 6 French (Fr) high-flow guide catheter (0.068 inch minimum internal diameter), which allows sufficient passage of the Catheter with adequate clearance for injection of standard contrast media, if desired. Cardiac arrhythmias during Catheter operation have been reported in a small number of patients. Cardiac rhythm should be monitored during Catheter use and appropriate management, such as temporary pacing, be employed if needed.³ Case Report A 55-year-old Caucasian woman presented to the Emergency Room with complaints of chest pain and syncope. A 12-lead electrocardiograph demonstrated ST-segment elevation in the inferior leads, consistent with an acute inferior wall myocardial infarction with reciprocal changes anterolaterally. She had a history of smoking and hypercholesterolemia. She was immediately taken to the cardiovascular lab for emergent percutaneous coronary intervention. A 6 Fr hockey stick with side holes guiding catheter (Cordis Corporation, Miami Lakes, FL) was used to engage the right coronary artery. Multiple small injections of Oxilan (Guerbet, Bloomington, IN) were made into the right coronary artery. Coronary angiography (Toshiba, Tustin, CA) showed a large-caliber dominant right coronary artery. There was a total occlusion at the mid portion of the right coronary artery with evidence of a thrombus burden (Figure 1). The patient was given a bolus of heparin 70 u/kg intravenously to maintain a therapeutic activated clotting time. In addition, a GP IIb/IIIa receptor blocker was initiated intravenously with a loading dose, followed by a maintenance drip. After therapeutic activated clotting time was obtained, a Balance Middle Weight 190 cm guidewire (Guidant Corporation, Santa Clara, CA) was advanced through the distal aspect of the right coronary artery. Following the guidewire insertion, a 4 Fr XMI-Rapid exchange rheolytic thrombectomy catheter (Possis Medical) was advanced over the wire to the thrombus burden. The initial pass of the AngioJet catheter was delivered though the lesion (Figure 2). Subsequently, two additional passes were delivered with the AngioJet catheter (Figures 3-4). Following the first two AngioJet passes, a subsequent coronary angiogram revealed a diffuse stenosis of the right coronary artery from the mid portion down to the posterior descending artery. Two hundred mcg of nitroglycerin was given, and after some time, it was evident that the stenosis following AngioJet was due to vasospasms of the right coronary artery. The right coronary artery was dilated and revealed the posterior descending artery and posterolateral LV branches to be normal. However, there was a persistent stenosis at the mid portion of the right coronary artery. The vasospasms subsequently resolved and revealed that the posterior descending artery and posterolateral LV branches were normal. However, there was a persistent stenosis at the mid portion of the right coronary artery. Therefore, a 3.5 x 18 mm Zeta Stent (Guidant) was deployed at the lesion site to 10 atmospheric pressure. Subsequent coronary angiogram revealed a widely patent right coronary artery (Figure 5). After rheolytic thrombectomy therapy, the electrocardiogram revealed normalization of the ST segment to baseline. The client also expressed resolution of her of chest pain. The following day, laboratory results revealed a decrease in creatine kinase (CPK) and CPK-MB fraction. The client did well throughout her hospitalization course and was discharged without complications. Benefits of Rheolytic Thrombectomy In conclusion, the benefits seen in our cardiovascular lab with the use of rheolytic thrombectomy in conjunction with PCI include, but are not limited to: 1. Quick restoration of blood flow to the coronary artery, reducing the occurrence of arrhythmias; 2. Reduction of thrombus burden to reveal the true lesion size; 3. Decreased time in the cardiovascular laboratory; 4. Reduced distal microvasculature embolization. A Final Note We feel that AngioJet is a personal choice versus a technical choice, and we have seen the best results from AngioJet use in those patients presenting with ST-segment elevation MI. We choose to use AngioJet in almost all of our ST-segment elevation MI cases. The only time in which we do not use AngioJet for these specific cases is when we are unable to pass the AngioJet catheter, or if there was difficulty passing the catheter, causing a time delay. Within the past year, we have successfully used AngioJet in approximately 40 out of 50 ST-segment elevation MI cases. Please address question or comments to: Jill Price RN, BSN, Assistant Vice President of Patient Care Services, Governor Juan F. Luis Hospital 4007 Estate Diamond Ruby, C’sted, St. Croix, USVI 00820. Email: jprice@jflusvi.org or Kendall Griffith MD, FACC, FSCAI, Medical Director Governor Juan F. Luis Hospital. Email kgriffith@jflusvi.org or kgriffithmd@aol.com

1. American College of Cardiology Clinical Statements and Guidelines. Retrieved from http://www.acc.org/clinical/statements.htm

2. Popma, Jeffery, M.D., (2003, September) Educational animations with full narration. AngioJet ® rheolytic thrombectomy system, Possis Medical, Inc.

3. Possis Medical. (2002). XMI-Rapid exchange rheolytic thrombectomy catheter information for use.