Intracoronary Administration of Thrombolysis for Severe Coronary Artery Ectasia Presenting as an Acute Inferior ST-Segment Elevation Myocardial Infarction

J INVASIVE CARDIOL 2017;29(10):E153.

Key words: percutaneous coronary intervention, intracoronary thrombus, thrombolysis, coronary artery ectasia

We present a 75-year-old male with acute inferior ST-elevation myocardial infarction, severe coronary artery ectasia (CAE), and large thrombus burden in the right coronary artery (RCA) (Figure 1A).

A Rinato wire (Asahi Intecc) was used and coronary blood flow was restored with sequential inflation of a Sprinter Legend Rx compliant balloon (Medtronic) increasing in diameter from 3.0 mm to 4.0 mm, but the large thrombus burden remained (Figure 1B). Despite attempts of manual aspiration with a 6 Fr Export Advance aspiration catheter (Medtronic) and intracoronary administration of glycoprotein IIb/IIIa inhibitor, there was very limited improvement in the thrombus burden. Therefore, we administered intracoronary tenecteplase at a low dose (10 mg) to further decrease the thrombus burden. On repeat angiography after 48 hours, the thrombus burden had significantly reduced with marked improvement in coronary blood flow (Figures 1C, 1D). The patient experienced no major bleeding complications during his hospital stay and remains stable and asymptomatic at 30-day follow-up.

CAE is an uncommon but well recognized condition of abnormally dilated coronary arteries. It often results in angina and increases the risk of myocardial infarction and sudden cardiac death due to slow flow, vasospasm, dissection, or thrombosis.¹ In cases of myocardial infarction with large thrombus burden and failure of manual aspiration, intracoronary thrombolysis at a lower dose has been well documented in multiple studies,^2,3 demonstrating safety of use in an acute setting. Our case supports the use of intracoronary thrombolysis as a second-line therapy for a large thrombus burden in primary percutaneous coronary intervention.

References

1.    Hartnell GG, Parnell BM, Pridie RB. Coronary artery ectasia, its prevalence and clinical significance in 4993 patients. Br Heart J. 1985;54:392-395.

2.    Kelly RV, Crouch E, Krumnacher H, Cohen MG, Stouffer GA. Safety of adjunctive intracoronary thrombolytic therapy during complex percutaneous coronary intervention: initial experience with intracoronary tenecteplase. Catheter Cardiovasc Interv. 2005;66:327-332.

3.    Boscarelli D, Vaquerizo B, Miranda-Guardiola F, et al. Intracoronary thrombolysis in patients with ST-segment elevation myocardial infarction presenting with massive intraluminal thrombus and failed aspiration. Eur Heart J Acute Cardiovasc Care. 2014;3:229-236.

From Gold Coast University Hospital, Queensland, Australia.

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 24, 2017.

Address for correspondence: Dr Avadhesh Saraswat, Gold Coast University Hospital – Cardiology Department, 1 Hospital Boulevard, Southport, Queensland, Australia. Email: avadhesh_saraswat@hotmail.com