Coronary thrombus in patients undergoing primary PCI for STEMI: Prognostic significance and management

Abstract

Acute ST-elevation myocardial infarction (STEMI) usually results from coronary atherosclerotic plaque disruption with superimposed thrombus formation. Detection of coronary thrombi is a poor prognostic indicator, which is mostly proportional to their size and composition. Particularly, intracoronary thrombi impair both epicardial blood flow and myocardial perfusion, by occluding major coronary arteries and causing distal embolization, respectively. Thus, although primary percutaneous coronary intervention is the preferred treatement strategy in STEMI setting, the associated use of adjunctive antithrombotic drugs and/or percutaneous thrombectomy is crucial to optimize therapy of STEMI patients, by improving either angiographical and clinical outcomes. This review article will focus on the prognostic significance of intracoronary thrombi and on current antithrombotic pharmacological and interventional strategies used in the setting of STEMI to manage thrombotic lesions.© 2014 Baishideng Publishing Group Inc. All rights reserved. Key words: ST-elevation myocardial infarction; Intracoronary thrombosis; Primary percutaneous coronary intervention; Antithrombotic therapies; Coronary thrombectomyCore tip: Intracoronary thrombosis, is the basic pathophysiologic event in acute ST-elevation myocardial infarction (STEMI), and thrombi are very frequently detected in STEMI patients undergoing primary percutaneous coronary intervention (PPCI). Thrombus burden and components are important determinants of prognosis in STEMI, being well-known risk factors for longterm adverse cardiovascular events, distal embolization and stent thrombosis. As a result, percutaneous management of lesions with a consistent thrombotic burden is still challenging in the setting of PPCI for STEMI. Therefore, several pharmacological and interventional strategies, such as thrombectomy have been developed in order to improve PPCI's safety and efficacy, by reducing thrombus burden.

Determinants of angiographic thrombus burden and impact of thrombus aspiration on outcome in young patients with ST‐segment elevation myocardial infarction

“…The major cause of ST‐segment elevation myocardial infarction (STEMI) is coronary artery occlusion due to intra‐coronary thrombus formation . High intracoronary thrombotic burden in infarct related artery is not only related to stent thrombosis, distal embolization, no‐reflow phenomenon, larger infarct size, but also serves as an important determinant of increased cardiovascular morbidity and mortality in patients with STEMI . Despite effective strategies to reduce thrombus burden (TB) through the application of modern pharmacological treatment including glycoprotein IIb/IIIa antagonists and invasive strategy (thrombus aspiration, TA), the management of coronary thrombosis remains a clinical challenge in patients with STEMI .…”

“The Sticky LAD”: Large Intracoronary Thrombus in an Aneurysmal Left Anterior Descending Artery Presenting as ST-Elevation Myocardial Infarction

“…Detection of intracoronary thrombi heralds a poor prognosis in STEMI [1]. Effects of intracoronary thrombus impair epicardial flow by occlusion of major coronary vessels and impair perfusion of the myocardium by distal embolization.…”

“…Effects of intracoronary thrombus impair epicardial flow by occlusion of major coronary vessels and impair perfusion of the myocardium by distal embolization. Intracoronary thrombus is angiographically defined as the presence of a filling defect with either: 1) Total occlusion with convex, irregular, or hazy distal margins and post-injection contrast retention of staining; and 2) Partial occlusion circumferentially outlined by contrast medium [1]. Thrombus may be graded (TG) by the TIMI thrombus grading.…”

“…Due to the large coronary segments and heavy thrombus burden, standard treatment may fail. Distal microembolization and improper stent sizing among these patients also raised concern during early percutaneous coronary intervention (PCI) in ACS [1]. We present a case of a patient with diffuse coronary ectasia and a large intracoronary thrombus presenting with STelevation myocardial infarction (STEMI).…”

The Results of Delayed Endovascular Intervention in St Elevation Acute Myocardial Infarction Due to Thrombotic Occlusion of Coronary Artery

“…Задержка с имплантацией стента в течение нескольких сут. позволяет значимо уменьшить объем или полностью ликвидировать тромботический материал в инфарктответственной артерии, и как следствие, снизить риск дистальной эмболизации и улучшить прогноз [4,5]. Установлено, что ИМ↑ST в большинстве случаев обусловлен тромботической окклюзией магистральной артерии, и у ²/ ³ пациентов сопровождается наличием массивного тромбоза по данным ангиографической оценки индекс коронарного тромбоза -TTG ≥3) (TIMI thrombus grade score) (TTG 3) [5,6].…”