Case 14: PCI Manual: Large coronary thrombus

Acute posterior myocardial infarction treated with primary PCI. Both the right coronary artery and the circumflex were occluded. A brief attempt to cross the RCA was unsuccessful (chronic occlusion) followed by PCI of the circumflex (culprit lesions). Large thrombus burden was present embolizing distally. Successful recanalization was achieved after multiple rounds of thrombectomy

[@schiefix]

That is actually a great De´Winter ECG pattern, a STEMI equivalent!

[@movvasrinivas1]

It was mentioned that we can perform aspiration thru a guide extension . Any tips ?

[@manosbrilakis]

1. Use balloon-assisted tracking to deliver the guide extension to the site of the thrombus (czcams.com/video/Gm2X2tIKxyU/video.html) 2. Use 40-50 cc syringes to aspirate through the side port of the touhy 3. Empty the syringe on a new gauze every time to see if you are capturing thrombus 4. Continue aspirating until no thrombus is being retrieved.

[@micger]

Did you perform balloon angioplasty across the side hole of stent into the AV circumflex? If not are you worried about the stent struts lying acrossthe AV circumflex potentially leading to restenosis and thrombosis?

[@manosbrilakis]

No we did not because we thought the AV circumflex was of small caliber. This is something that can be done especially for larger vessels.

[@micger]

Thanks for your reply. If the AV circumflex was a bigger vessel how would you open up the struts? Would you do kissing balloon or just a single balloon inflation across the struts? And how would you size your balloon in the AV circumflex - 1:1 or smaller?

[@manosbrilakis]

Ideally kissing balloon inflation - side branch balloon slightly undersized to minimize risk for dissection.

[@micger]

Thanks!