Multivessel Coronary Artery Thrombosis

From the Department of Medicine, Division of Cardiology, Beth Israel Medical Center, New York, New York. The authors report no conflicts of interest regarding the content herein. Manuscript submitted September 9, 2008, provisional acceptance given October 21, 2008, final version accepted November 3, 2008. Address for correspondence: Yumiko Kanei, MD, Beth Israel Medical Center, Cardiac Catheterization Laboratory, 11 Dazian, 1st Avenue at 16th Street, New York, NY 10003. E-mail: yumikanei@hotmail.com

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ABSTRACT: Simultaneous thrombosis of multiple epicardial coronary arteries is an uncommon clinical finding in ST-segment elevation myocardial infarction (STEMI). We describe a 37-year-old male present with inferior wall STEMI who was found to have large thrombi in both the right coronary artery (RCA) and the left anterior descending artery (LAD). We reviewed 23 patients with multivessel thrombosis in acute myocardial infarction in the literature. The mean age of patients was 53 ± 14 years (32–82 years); 74% were males, and most patients had multiple risk factors for coronary artery disease. The LAD (78%) and RCA (87%) were the arteries involved for most patients. Aspiration thrombectomy was used in 3 cases. Though it is rare, STEMI with multiple culprit arteries can occur, and it is crucial to recognize this condition to determine the proper treatment, since most of these patients are critically ill.

J INVASIVE CARDIOL 2009;21:66–68

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Simultaneous thrombosis of multiple epicardial coronary arteries is an uncommon clinical finding in ST-segment elevation myocardial infarction (STEMI). Most patients with acute multivessel thrombosis are critically ill, and the recognition of this condition is of paramount importance to enable prompt and appropriate management. We present a case and review all previously reported cases of multiple coronary thromboses.

Index Case

A 37-year-old male bartender of Middle-Eastern descent presented to the emergency department with complaints of sudden-onset retrosternal chest discomfort followed by syncope while at work. His initial vital signs showed a regular heart rate of 45 beats per minute, a blood pressure of 111/43 mmHg, a respiratory rate of 12 per minute and an oxygen saturation of 88% on room air. There was jugular venous distension, but the remainder of the physical examination was unremarkable. The patient was unresponsive on arrival, developed progressive respiratory distress and was immediately intubated and placed on mechanical ventilatory support. Electrocardiography (ECG) demonstrated sinus rhythm with complete atrioventricular block, ST-segment elevation in leads II, III, aVF, and ST-segment depression in leads I, aVl and V2–V4 (Figure 1). He was referred for emergent cardiac catheterization. His prior medical history was significant for mild diet-controlled hypertension. He smoked 1 pack of cigarettes a day and occasionally drank alcohol. He denied using cocaine, but admitted occasional use of marijuana. His father had died of an acute MI at the age of 50. The patient became hypotensive, and a transvenous pacemaker and an intra-aortic balloon pump were placed for hemodynamic support. Coronary angiography showed flow-limiting stenosis with a large thrombus in the proximal and middle right coronary artery (RCA) with TIMI 2 flow (Figure 2A). Following successful balloon angioplasty, a Liberté 4.5 mm x 20 mm bare-metal stent (Boston Scientific Corp., Natick, Massachusetts) was placed, resulting in TIMI 3 flow. Selective left coronary artery angiography demonstrated a large mobile thrombus in the proximal left anterior descending artery (LAD) at the bifurcation of first diagonal branch with TIMI 3 flow (Figure 2B). Left ventriculography revealed an ejection fraction of 30% with akinesis of the inferior wall and severe hypokinesis of the mid and distal anterior and apical walls. The patient received unfractionated heparin and front-loading of a glycoprotein IIb/IIIa antagonist (abciximab). He was placed on dual antiplatelet therapy with aspirin and clopidogrel and was continued on intravenous unfractionated heparin. Initial laboratory data showed a hemoglobin of 12.6 g/dl. The patient’s white cell count was 15.4/mm³, his platelet count was 167,000/mm³, and his creatinine was 1.4 mg/dl. His peak troponin I was 327 ng/mL and his peak creatine-kinase was 13,312 U/L. The patient was extubated on day 6, and remained clinically stable. Evaluation for hypercoagulability, including lupus anticoagulant, anticardiolipin IgM and IgG and Factor V Leiden, were all negative. His platelet count trended up to 900,000/mm³ on day 12, but the hematologic evaluation, including bone marrow biopsy, did not demonstrate essential thrombocythemia or any other myeloproliferative diseases. The patient’s platelet count gradually decreased to normal levels by day 16. He underwent repeat coronary angiography to reevaluate the LAD lesion 13 days later, which demonstrated complete resolution of the thrombus with a residual significant obstructive lesion at the bifurcation of the LAD and the diagonal branch. Repeat echocardiography showed a left ventricular ejection fraction of 15%. The patient underwent successful coronary artery bypass graft surgery.

Literature Review

A comprehensive Medline database search for literature published in English was performed using PubMed (National Library of Medicine, Bethesda, Maryland). The search terms were: “multivessel coronary thrombosis”, “simultaneous coronary thrombosis” and “acute myocardial infarction and multiple thrombosis”. The references in the articles were examined for additional relevant studies. All reports were carefully examined, and in addition to the cases with multiple thrombi, cases with simultaneous coronary artery occlusion were also included if the presentation was consistent with acute multivessel occlusion. We found 23 cases of patients with multivessel thrombosis in acute MI (1 case of acute coronary syndrome), including the case presented in this article¹⁷ (Table 1). The mean age of the patients was 53 ± 14 years (32–82 years), 74% were males and most patients had multiple risk factors for coronary artery disease. Smoking was particularly noted as a risk factor in 48% of patients. Some patients had other possible causes for multiple thromboses, and 4 patients had essential thrombocytosis. The LAD (78%) and RCA (87%) were the arteries involved in most patients, and 6 patients had simultaneous total occlusion of 2 arteries. Twelve patients (52%) were treated with 2 stents, and 4 patients (17%) with 1 stent. Aspiration thrombectomy was used in 3 cases.

Discussion

We present the largest review of the literature with a description of a case of multivessel acute coronary thrombosis. Acute MI with multiple thromboses of major coronary arteries is an infrequent clinical and angiographic finding. Several possible underlying conditions for multiple coronary thromboses have been suggested, such as cocaine use, hypercoagulable state and essential thrombocytosis. Several case reports of patients with essential thrombocytosis resulting in multivessel coronary thrombosis have been published.^1,4,8,14 Although our patient had an increase in platelet count after the event, the bone marrow biopsy result was not consistent with essential thrombocytosis. Reactive thrombocytosis after acute MI has been reported to be a relatively common finding.¹⁸ Although multiple coronary thromboses are extremely rare in current clinical practice, pathological studies have shown that epicardial coronary thromboses were found in 10% of patients who died from acute MI.¹⁹ Patients with multiple thromboses tend to be more critically ill, as 50% of the patients described in the literature, including our current case, presented with cardiogenic shock. These patients may presumably be the ones who develop out-of-hospital cardiac arrest and death, and hence, the possibility of this condition may be underestimated. Acute multiple coronary thromboses may be associated with a systemic prothrombotic condition, hence the term “pancoronaritis”.²⁰ Previous studies using angioscopy and IVUS showed that multiple plaque ruptures are frequent in acute coronary syndromes and can be detected in different coronary arteries.^21,22 Another possible mechanism is that the first event causing impairment of the flow of other vessels can lead to acute secondary thrombosis. In addition, the possibility of multiple coronary emboli due to aortic or mitral valve endocarditis²³ and paradoxical emboli through an intracardiac shunt must be considered in patients with no risk factors for coronary artery disease. Our patient was treated with primary angioplasty and stent placement in the RCA and medical therapy for the LAD, resulting in resolution of the thrombus by day 13. In most recently-reported cases, both arteries were treated with stents, but Turgeman et al¹⁷ presented a case that was successfully treated with balloon angioplasty and thrombus aspiration. A recent randomized trial²⁴ showed a benefit of thrombus aspiration in ST-segment elevation MI resulting in better reperfusion, and this approach is probably helpful in a subset of patients with a high thrombus burden.

Conclusion

Multiple epicardial coronary thromboses occurring in a patient with STEMI is unusual. Despite the inherent tendency to contribute acute MI to a single culprit lesion, STEMI with multiple culprit arteries can occur, and it is crucial to recognize this condition to determine the appropriate treatment since most of these patients are critically ill.

References

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