Embolization of a Large Intracoronary Thrombus During ST-Segment Elevation Myocardial Infarction

J INVASIVE CARDIOL 2017;29(10):E149-E150.

Key words: intracoronary thrombus, STEMI, embolization

A 69-year-old woman with dementia, hypertension, hyperlipidemia, coronary artery disease, and prior percutaneous coronary intervention (PCI) of the right coronary artery (RCA) presented to the emergency department with syncope. Initial vital signs were notable for hypotension and bradycardia. Electrocardiography revealed sinus rhythm with complete atrioventricular block, a junctional escape rhythm, and 5 mm ST-segment elevations in the inferior leads, consistent with acute myocardial infarction. Loading doses of aspirin and ticagrelor were administered in the emergency department, and the patient was referred for emergent coronary angiography. Angiography of the RCA in a left anterior oblique view with cranial angulation revealed a large burden of thrombus in the proximal RCA (Figure 1) and distal embolization of the thrombus during contrast injection (Figure 2). Intravenous bivalirudin and cangrelor were immediately administered. Aspiration thrombectomy was performed with retrieval of the intact thrombus. Bradycardia and hypotension rapidly resolved. Balloon angioplasty was performed at the site of proximal RCA in-stent restenosis with improved angiographic appearance and TIMI 3 flow in the major branches at the conclusion of the case (Figure 3) (Video 1). The patient was transferred to the intensive care unit for further management.

The latest American College of Cardiology/American Heart Association/Society of Cardiovascular Angiography and Interventions (ACC/AHA/SCAI) focused update on primary PCI for patients with ST-elevation myocardial infarction (STEMI) guidelines provide a class IIb recommendation for bailout aspiration thrombectomy during primary PCI, based on data from large randomized controlled trials.^1-3 However, select patients with very high thrombus burden and associated hemodynamic instability, as shown here, may still derive clinical benefit from thrombus aspiration in STEMI.

References

1.    Lagerqvist B, Frobert O, Olivecrona GK, et al. Outcomes 1 year after thrombus aspiration for myocardial infarction. N Engl J Med. 2014;371:1111-1120.

2.    Jolly SS, Cairns JA, Yusuf S, et al. Randomized trial of primary PCI with or without routine manual thrombectomy. N Engl J Med. 2015;372:1389-1398.

3.    Levine GN, Bates ER, Blankenship JC, et al. 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. J Am Coll Cardiol. 2016;67:1235-1250.

From the Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript accepted April 17, 2017.

Address for correspondence: Nathaniel R. Smilowitz, MD, New York University School of Medicine, 550 1st Avenue, HCC-14th Floor, New York, NY 10016. Email: Nathaniel.Smilowitz@nyumc.org