Case 35: PCI Manual- Large RCA thrombus
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- čas přidán 7. 09. 2024
- A patient presented with inferior STEMI and a large right coronary artery thrombus. Aspiration attempts with an aspiration catheter, aspiration through a guide catheter extension, and retrieval using a Filterwire failed. The thrombus embolized distally compromising distal flow and laser failed to improve the flow. The patient had multiple episodes of ventricular fibrillation requiring defibrillation. He eventually stabilized on an epinephrine drip, obviating the need for inserting a right ventricular support device.
In cases of large intracoronary thrombus, conservatibve management with antithrombotic therapy (usually glycoprotein IIb/IIIa inhibitors and heparin) may allow resolution of the thrombus within 2-3 days, reducing the risk of embolization during PCI.
Dr. Brilakis your videos are inspirational and help so many patients. I am grateful for you for sharing your experiences
My dad was diagnosed with artry disease,postero inferior mi . High LDL levels, caused heavy thrombus burden In RCA, went through angioplasty and tried to open the blockage by going through 2 events.. Both were complicated and failed,
LAD had 2- 95% stenosis and treated well with DEB, while another 95% stenosis in LCX was stented successfully . cardiology committee decided to leave RCA as it is as long as my dad is. Not feeling any chest pain, something like well collateralized from left part was written in the report but didn't get it. and left. For. Medical management , he is taking lipitor, aspirin, brilinta, coversyl, concor...
After discharging him in the same day returned to emergency due to liquids retention in chest.. Had another IHD due to this.. Treated with Larix.. And dischared later after 3 days.. Now thanks to god he is well.. Loosing weight, diet, good medication, he is not feeling anything irregular in his chest..slight cough. I hope he will be fine
Please POST A VIDEO of this case after 48 hrs! It is very intersting to see the result of thrombolytic therapy. Thank you
There was no cath after 48 hours. Patient recovered and did not have repeat cath.
@@manosbrilakis glad to hear that patient is ok
Just thanks for your sharing. 2 experiences of IC thrombolysis I have, 1 OK, 1 have gumb bleeding. Feels it much dangerous.
I have seen several cases like this with large thrombus and essentially TIMI3 flow. If there is TIMI3 flow there is in my oppinion no clear indication to do something, as lots of things you can do will make things worse (as in this case). "Marinading" the patient in Gp2b3a can make miracles, and on repeat Angio 2-3d later the thrombus often has disappeared completely (as Dr Brilakis said). That´s the way it is done in the UK.
Thank you for sharing! but i didn't aspirate! if i were you, i use heparin and anticoagulation! INR target is 2.0 and angiogram will be performed after a week!
Thank you for the suggestion.
Does there is any role of administration of fibrinolytic therapy in such cases?
I have not given intracoronary thrombolytics and I am personally skeptical about potential complications (although radial access would help reduce risk for access site bleeding). There are some series showing promising results: Eur Heart J Acute Cardiovasc Care. 2014 Sep;3(3):229-3.
Nice
What are your thoughts on Angiojet Ultra (coronary)? Was this an option for you in this case? Thank you for sharing your cases!
I would not use Angiojet: in the AIMI trial (J Am Coll Cardiol. 2006 Jul 18;48(2):244-52) use of AngioJet was associated with larger MI size and higher mortality. A potential option is "BADI" (balloon-assisted deep intubation), i.e. deep intubation of a guide catheter and aspiration from the guide.
Manos Brilakis Thanks for your reply!
Think M-guard could have a good role here. Good case nonetheless
What is your experience with the penumbra aspiration catheter in cases like this?
Filter wire placed, why did you not place mash stent, or even ordinary stent with prolonged inflation?
Mesh stents are not available in the US. Any stents would carry high risk for distal embolization.
How about intra coronary thrombolytics?
should upstream adenosine/nicardipin infusion (prior to stenting) be resolution for this scenario?
It could possibly help. Another option if no reflow occurs is intracoronary epinephrine.
Great case!
Did you use contrast with laser atherectomy ?
Thank you so much!
Did not use contrast with laser - contrast with laser is for balloon undilatable lesions, not for thrombus.
Why not Angiojet?
Could the patient be sent for emergency CABG?
This could be an option, but might not have helped as there was massive thrombus in the distal RCA and also placing the patient on cardiac bypass might further impair RV function.
What happened to patient after?
Patient recovered. Epinephrine infusion was stopped the following day. He did not have recurrent symptoms and no repeat angiography was done.
Do you think the thrombus has resolved with return of antegrade flow in RCA or the mid RCA remained obstructed with collaterals from the left system? The fact that patient remained asymptomatic with resolution of ST segments at the end of the case would suggest the latter?
Impossible to know for sure, but the patient's clinical improvement suggests that at least some reperfusion was achieved.
Fair enough. Thank you very much for sharing! I always look forward to your interesting cases.
Manos Brilakis what antiplatelet regimen is he on now?