Large intracoronary thrombus and its management during primary PCI

Vinod Kumar, Ajay Kumar Sharma, Tarun Kumar, Ranjit Kumar Nath, Vinod Kumar, Ajay Kumar Sharma, Tarun Kumar, Ranjit Kumar Nath

Abstract

Large intracoronary thrombus has been reported in significant number of patients with STEMI. Primary PCI is the current standard of care in patients of STEMI. Despite the availability of dual antiplatelets, GP IIb/IIIa inhibitor and effective anticoagulation regimens, large intracoronary thrombus remains one of the biggest challenge to interventional cardiologists during primary PCI. Large intracoronary thrombus may lead to distal embolization, no/slow reflow or embolization into a non-culprit vessel and is associated with adverse cardiovascular outcome. There is no ideal management strategy. We hereby discuss the current available methods/strategies to deal with large thrombus burden encountered during primary PCI, in the current manuscript.

Keywords: Embolic protection device; Large thrombus burden; Primary PCI; Thrombectomy; Thrombus aspiration.

Conflict of interest statement

Conflict of interest None.

Copyright © 2020 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.

Figures

Fig. 1
Fig. 1
Proposed algorithm for management of large thrombus burden during primary PCI (modified from reference 58).

References

    1. Sianos G., Papafaklis M.I., Daemen J. Angiographic stent thrombosis after routine use of drug-eluting stents in ST-segment elevation myocardial infarction: the importance of thrombus burden. J Am Coll Cardiol. 2007;50:573–583.
    1. Miranda Guardiola F., Rossi A., Serra A. On behalf of the Spanish AMI cath Registry. Angiographic quantification of thrombus in ST-elevation acute myocardial infarction presenting with an occluded infract-related artery and its relationship with outcomes of percutaneous intervention. J Intervent Cardiol. 2009;22:207–215.
    1. Fukuda D., Tanaka A., Shimada K. Predicting angiographic distal embolization following percutaneous coronary intervention in patients with acute myocardial infarction. Am J Cardiol. 2003;91:403–407.
    1. Farb A., Burke A.P., Tang A. Coronary plaque erosion without rupture into a lipid core: a frequent cause of coronary thrombosis in sudden coronary death. Circulation. 1996;93:1354–1363.
    1. Falk E., Shah P.K., Fuster V. Coronary plaque disruption. Circulation. 1995;92(3):657–671.
    1. Nabel E.G., Braunwald E. A tale of coronary artery disease and myocardial infarction. N Engl J Med. 2012;366(1):54–63.
    1. Davies M.J. The pathophysiology of acute coronary syndromes. Heart. 2000;83:361–366.
    1. Gibson C.M., de Lemos J.A., Murphy S.A. Combination therapy with abciximab reduces angiographically evident thrombus in acute myocardial infarction: a TIMI 14 substudy. Circulation. 2001;103(21):2550–2554.
    1. Niccoli G., Spaziani C., Marino M. Effect of chronic Aspirin therapy on angiographic thrombotic burden in patients admitted for a first ST-elevation myocardial infarction. Am J Cardiol. 2010;105:587–591.
    1. Topaz O., Topaz A., Owen K. Thrombus grading for coronary interventions: the role of contemporary classifications. Intervent Cardiol. 2011;3:705–712.
    1. Yip H.K., Chen M.C., Chang H.W. Angiographic morphologic features of infarct-related arteries and timely reperfusion in acute myocardial infarction: predictors of slow-flow and no-reflow phenomenon. Chest. 2002;122(4):1322–1332.
    1. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2018;39:119–177.
    1. Hermanides R.S., Kilic S., van 't Hof A.W.J. Optimal pharmacological therapy in ST-elevation myocardial infarction-a review : a review of antithrombotic therapies in STEMI. Neth Heart J. 2018;26(6):296–310.
    1. ESPRIT Investigators. Enhanced Suppression of the Platelet IIb/IIIa Receptor with Integrilin Therapy Novel dosing regimen of eptifibatide in planned coronary stent implantation (ESPRIT): a randomised, placebo-controlled trial. Lancet. 2000;356(9247):2037–2044. [published correction appears in Lancet 2001 Apr 28;357(9265):1370]
    1. De Luca G., Savonitto S., van't Hof A.W. Platelet GP IIb-IIIa receptor antagonists in primary angioplasty: back to the future. Drugs. 2015;75(11):1229–1253.
    1. Muhlestein J.B., Karagounis L.A., Treehan S. "Rescue" utilization of abciximab for the dissolution of coronary thrombus developing as a complication of coronary angioplasty. J Am Coll Cardiol. 1997;30:1729–1734.
    1. Ellis S.G., Tendera M., de Belder M.A., FINESSE Investigators Facilitated PCI in patients with ST-elevation myocardial infarction. N Engl J Med. 2008;358(21):2205–2217.
    1. Winchester D.E., Wen X., Brearley W.D. Efficacy and safety of glycoprotein IIb/IIIa inhibitors during elective coronary revasclarization: a meta-analysis of randomized trials performed in the era of stents and thienopyridines. J Am Coll Cardiol. 2011;57:1190–1199.
    1. Mehilli J., Kastrati A., Schulz S. Abciximab in patients with acute ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention after clopidogrel loading: a randomized double-blind trial. Circulation. 2009;119(14):1933–1940.
    1. Hermanides R.S., van Werkum J.W., Ottervanger J.P. The effect of pre-hospital glycoprotein IIb–IIIa inhibitors on angiographic outcome in STEMI patients who are candidates for primary PCI. Cathet Cardiovasc Intervent. 2012;79:956–964. doi: 10.1002/ccd.23165.
    1. Gurbel P.A., Tantry U.S. Delivery of glycoprotein IIb/IIIa inhibitor therapy for percutaneous coronary intervention: why not take the intracoronary highway? Circulation. 2010;121:739–741.
    1. Gu Y.L., Kampinga M.A., Wieringa W.G. Intracoronary versus intravenous administration of abciximab in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention with thrombus aspiration: the comparison of intracoronary versus intravenous abciximab administration during emergency reperfusion of ST-segment elevation myocardial infarction (CICERO) trial. Circulation. 2010;122:2709–2717.
    1. Thiele H., Wöhrle J., Hambrecht R. Intracoronary versus intravenous bolus abciximab during primary percutaneous coronary intervention in patients with acute ST-elevation myocardial infarction: a randomised trial. Lancet. 2012;379:923–931.
    1. Shimada Y.J., Nakra N.C., Fox J.T. Meta-analysis of prospective randomized controlled trials comparing intracoronary versus intravenous abciximab in patients with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention. Am J Cardiol. 2012;109:624–628.
    1. Zeymer Uwe, Rao Sunil V., Montalescot Gilles. Anticoagulation in coronary intervention. Eur Heart J. 1 December 2016;37(Issue 45):3376–3385.
    1. Montalescot G., Zeymer U., Silvain J., ATOLL Investigators Intravenous enoxaparin or unfractionated heparin in primary percutaneous coronary intervention for STelevation myocardial infarction: the international randomised open-label ATOLL trial. Lancet. 2011;378(9792):693–703.
    1. Silvain J., Beygui F., Barthelemy O. Efficacy and safety of enoxaparin versus unfractionated heparin during percutaneous coronary intervention systematic review and meta-analysis. BMJ. 2012;344 e553.
    1. Capodanno D., Gargiulo G., Capranzano P. Bivalirudin versus heparin with or without glycoprotein IIb/IIIa inhibitors in patients with STEMI undergoing primary PCI: an updated meta-analysis of 10,350 patients from five randomized clinical trials. Eur Heart J Acute Cardiovasc Care. 2016;5(3):253–262.
    1. Yusuf S., Mehta S.R., Chrolavicius S. Effects of fondaparinux on mortality and reinfarction in patients with acute ST-segment elevation myocardial infarction the OASIS-6 randomized trial. J Am Med Assoc. 2006;295:1519–1530.
    1. Werner G.S., Lang K., Kuehnert H. Intracoronary verapamil for reversal of No-reflow during coronary angioplasty for acute myocardial infarction. Cathet Cardiovasc Interv. 2002;57:444–451.
    1. Amit G., Cafri C., Yaroslavtsev S. Intracoronary nitroprusside for the prevention of the no-reflow phenomenon after primary percutaneous coronary intervention in acute myocardial infarction. A randomized, double-blind, placebo-controlled clinical trial. Am Heart J. 2006;152(5):887. e9-887.e8.87E14.
    1. Micari A., Belcik T.A., Balcells E.A. Improvement in microvascular reflow and reduction of infarct size with adenosine in patients undergoing primary coronary stenting. Am J Cardiol. 2005;96(10):1410–1415.
    1. Huang D., Qian J., Ge L. REstoration of COronary flow in patients with no-reflow after primary coronary interVEntion of acute myocaRdial infarction (RECOVER) Am Heart J. 2012;164:394–401.
    1. Huang R.I., Patel P., Walinsky P. Efficacy of intracoronary nicardipine in the treatment of no-reflow during percutaneous coronary intervention. Cathet Cardiovasc Interv. 2006;68:671–676.
    1. Boscarelli D., Vaquerizo B., Miranda-Guardiola F. 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(3):229–236.
    1. Greco C., Pelliccia F., Tanzilli G. Usefulness of local delivery of thrombolytics before thrombectomy in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention (the delivery of thrombolytics before thrombectomy in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention [DISSOLUTION] randomized trial) Am J Cardiol. 2013;112(5):630–635.
    1. McCartney P.J., Eteiba H., Maznyczka A.M. Effect of low-dose intracoronary alteplase during primary percutaneous coronary intervention on microvascular obstruction in patients with acute myocardial infarction. A randomized clinical trial. J Am Med Assoc. 2019;321:56–68.
    1. Burzotta F., Trani C., Romagnoli E. Manual thrombus-aspiration improves myocardial reperfusion: the randomized evaluation of the effect of mechanical reduction of distal embolization by thrombus-aspiration in primary and rescue angioplasty (REMEDIA) trial. J Am Coll Cardiol. 2005;46:371–376.
    1. Vlaar P.J., Svilaas T., van der Horst I.C. Cardiac death and reinfarction after 1 year in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS): a 1-year follow-up study. Lancet. 2008;371:1915–1920.
    1. Frobert O., Lagerqvist B., Olivecrona G.K. Thrombus aspiration during ST-segment elevation myocardial infarction (TASTE) N Engl J Med. 2013;369:1587–1597.
    1. Jolly S.S., Cairns J., Yusuf S. Design and rationale of the TOTAL trial: a randomized trial of routine aspiration ThrOmbecTomy with percutaneous coronary intervention (PCI) versus PCI ALone in patients with ST-elevation myocardial infarction undergoing primary PCI. Am Heart J. 2014;167:315–321. e1.
    1. Migliorini A., Stabile A., Rodriguez A.E. JETSTENT Trial Investigators. Comparison of AngioJet rheolytic thrombectomy before direct infarct artery stenting with direct stenting alone in patients with acute myocardial infarction. The JETSTENT trial. J Am Coll Cardiol. 2010;56:1298–1306.
    1. Young J.J., Cox D.A., Stuckey T. Prospective, multicenter study of thrombectomy in patients with acute myocardial infarction: the X-tract AMI registry. J Intervent Cardiol. 2007;20:44–50.
    1. Lefèvre T., Garcia E., Reimers B. X-sizer for thrombectomy in acute myocardial infarction improves ST-segment resolution: results of the X-sizer in AMI for negligible embolization and optimal ST resolution (X AMINE ST) trial. J Am Coll Cardiol. 2005 Jul 19;46(2):246–252.
    1. Topaz O., Ebersole D., Das T. Excimer laser angioplasty in acute myocardial infarction (the CARMEL multicenter trial) Am J Cardiol. 2004;93:694–701.
    1. Stone G.W., Webb J., Cox D.A. Enhanced Myocardial Efficacy and Recovery by Aspiration of Liberated Debris (EMERALD) Investigators. Distal microcirculatory protection during percutaneous coronary intervention in acute ST-segment elevation myocardial infarction: a randomized controlled trial. J Am Med Assoc. 2005;293:1063–1072.
    1. Muramatsu T., Kozuma K., Tsukahara R. ASPARAGUS Trial Investigators. Comparison of myocardial perfusion by distal protection before and after primary stenting for acute myocardial infarction: angiographic and clinical results of a randomized controlled trial. Cathet Cardiovasc Interv. 2007;70:677–682.
    1. Kelbaek H., Terkelsen C.J., Helqvist S. Randomized comparison of distal protection versus conventional treatment in primary percutaneous coronary intervention: the drug elution and distal protection in ST-elevation myocardial infarction (DEDICATION) trial. J Am Coll Cardiol. 2008;51:899–905.
    1. Sievert H., Wahr D.W., Schuler G. Effectiveness and safety of the Proxis system in demonstrating retrograde coronary blood flow during proximal occlusion and in capturing embolic material.(FASTER) trial. Am J Cardiol. 2004;94:1134–1139.
    1. Haeck J.D., Koch K.T., Gu Y.L. Proximal embolic protection in patients undergoing primary angioplasty for acute myocardial infarction (PREPARE): core lab adjudicated angiographic outcomes of a randomised controlled trial. Neth Heart J. 2010;18:531–536.
    1. Alak A., Lugomirski P., Aleksova N. A meta-analysis of randomized controlled trials of conventional stenting versus direct stenting in patients with acute myocardial infarction. J Invasive Cardiol. 2015;27:405–409.
    1. Stone G.W., Abizaid A., Silber S. Prospective, randomized, multicenter evaluation of a polyethylene terephthalate micronet meshcovered stent (MGuard) in ST-segment elevation myocardial infarction: the MASTER trial. J Am Coll Cardiol. 2012;60:1975–1984.
    1. Stone G.W., The MASTER II trial . The International Conference for Innovations Meeting. 2014. Comparison of the MGuard embolic protection stent with standard stent in acute myocardial infarction. Tel Aviv, Israel.
    1. van Geuns R.J., Yetgin T., La Manna A. STENTYS Self-Apposing sirolimus-eluting stent in ST-segment elevation myocardial infarction: results from the randomised APPOSITION IV trial. EuroIntervention. 2016;11:e1267–e1274.
    1. Mehran R. Society for 9 Cardiovascular Angiography and Interventions Scientific Sessions. 2016. Apposition V - STENTYS coronary stent system clinical trial in 8 subjects with ST elevation myocardial infarction. 10 2016; Orlando, Fla.
    1. Carrick D., Oldroyd K.G., McEntegart M. A randomized trial of deferred stenting versus immediate stenting to prevent No- or slow-reflow in acute ST-segment elevation myocardial infarction (DEFER-STEMI) J Am Coll Cardiol. 2014;63:2088–2098.
    1. Kelbaek H., Hofsten D.E., Kober L. Deferred versus conventional stent implantation in patients with ST-segment elevation myocardial infarction (DANAMI 3-DEFER): an open-label, randomised controlled trial. Lancet. 2016;387(10034):2199–2206.
    1. Choudry Fizzah A., Weerackody Roshan P., Jones Daniel A. Thrombus embolisation: prevention is better than cure. Intervent Cardiol. 2019;14(2):95–101.

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