Successful extraction of refractory thrombus from an ectatic coronary artery using stent retriever during primary angioplasty for acute myocardial infarction: a case report

Kesavamoorthy Bhoopalan, Ravindran Rajendran, Srinivasan Alagarsamy, Niranjana Kesavamoorthy, Kesavamoorthy Bhoopalan, Ravindran Rajendran, Srinivasan Alagarsamy, Niranjana Kesavamoorthy

Abstract

Background: Ectatic coronary segments are nidi for thrombus formation due to altered flow dynamics and stasis-an important component of Virchow's triad. Ectasia accompanied by an adjacent coronary stenosis with or without a plaque event can lead to acute myocardial infarctions complicated by huge thrombus burden.

Case summary: Here, we present a case of a young male with acute inferior wall myocardial infarction complicated by Type IV coronary artery ectasia of the right coronary artery and huge thrombus burden that was refractory to conventional methods of thrombus management like thrombo-suction and intracoronary cocktails including tenecteplase. After a stormy course of transient complete heart block and recurrent ventricular tachycardia, the thrombus was successfully extracted using a stent retriever to achieve thrombolysis in myocardial infarction (TIMI) II plus flow distally. The lesion just distal to the ectasia was stented 24 h later to achieve TIMI III flow and the patient had an uneventful recovery subsequently.

Discussion: Angiographically visible thrombus that is refractory to intracoronary medications and aspiration thrombectomy can be successfully managed using a stent retriever.

Keywords: Case report; Coronary artery ectasia; Solitaire AB; Thrombectomy; Thrombus retrieval.

Figures

Figure 1
Figure 1
(A) Electrocardiogram at presentation showing ST elevation inferior wall myocardial infarction. (B) Electrocardiogram after thrombus retrieval showed near complete resolution of ST segment in inferior leads. (C) Twenty-four hours later the electrocardiogram showed a small Q wave with complete ST-segment resolution. (D) The Q wave become deep and T wave got inverted after stenting.
Figure 2
Figure 2
(A) Occluded proximal right coronary artery. (B) Proximal right coronary artery coronary artery ectasia with a large thrombus. (C) Rebar micro-catheter tip at mid-right coronary artery and the wire removed. (D) Solitaire AB distal tip positioned in the mid-right coronary artery and partially unsheathed by pulling the micro-catheter out. (E) Pulling back the retriever into the guide catheter in the deployed state. (F) Retrieved thrombus. (G) Thrombolysis in myocardial infarction II flow in distal right coronary artery with a tight lesion just distal to the coronary artery ectasia. (H) Lesion being stented. (I) Final result after post-dilatation.
Figure 3
Figure 3
(A, B) Left coronary artery in caudal and cranial view showed minimal disease involving its branches.
Figure 4
Figure 4
Line diagram to illustrate the technique of using the thrombus retrieval device. (A) The vessel with thrombus is crossed with a workhorse wire that was pre-loaded with a Rebar micro-catheter. (B) Rebar micro-catheter was advanced beyond the thrombus. (C) The wire was removed; an appropriate sized Solitaire AB device was back loaded and advanced to the tip of the micro-catheter positioned beyond the thrombus. (D) The micro-catheter was pulled back maintaining the tip of the device at the same position. This makes the stent expand and trap the thrombus between its struts. (E) The stent device is then pulled back into the micro-catheter along with the trapped thrombus. (F) Once the device is completely within the micro-catheter the whole system is pulled out.

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Source: PubMed

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