Safety of adjunctive intracoronary thrombolytic therapy during complex percutaneous coronary intervention: Initial experience with intracoronary tenecteplase

Abstract

Intracoronary thrombus is associated with increased risk of in-laboratory vessel closure, recurrent myocardial infarction (MI), urgent vessel revascularization, and death. There is a lack of consensus on what represents the ideal treatment for patients with thrombotic complications during percutaneous coronary intervention (PCI), but the development of newer thrombolytic agents with increased fibrin specificity and longer half-life provides a potentially useful treatment option. In this study, the safety and efficacy of intracoronary tenecteplase (TNK) was evaluated in 34 patients (22 with acute ST elevation MI, 4 with rescue PCI, 6 with non-ST elevation MI, and 2 during elective PCI) who developed no-reflow, distal embolization, or visible intracoronary thrombus during PCI. The mean age was 57 years, 76% were Caucasian, and there were 14 women and 20 men. Cardiogenic shock was present in seven (21%) patients at baseline. All patients were being treated with aspirin and either unfractionated heparin (33 patients) or bivalrudin. Glycoprotein IIb/IIIa inhibitors were used in 76% of patients. Intracoronary TNK was used at a mean dose of 10.2 +/- 5.2 mg (median, 10 mg; range, 5-25 mg). There was one TIMI major bleeding event and three TIMI minor bleeding events. The mean hematocrit measured the morning following PCI was 35.5% +/- 4.9% in patients receiving TNK and 36.5% +/- 4.4% in a randomly selected sample of 150 consecutive patients undergoing PCI (P = 0.25). In conjunction with mechanical intervention, TNK was successful at dissolving angiographic thrombus and/or improving flow in 91% of patients. In conclusion, intracoronary TNK is safe and well tolerated in patients who develop thrombotic complications during complex PCI.

Successful Revascularization of Coronary Artery Occluded by Massive Intracoronary Thrombi with Alteplase and Percutaneous Coronary Intervention

“…Gurbel PA et al found that lesion-directed delivery of alteplase resulted in more prolonged local thrombolysis and thrombus score reduction in 45 unstable angina patients with coronary thrombus 10) . Recently, Kelly RV et al reported that the administration of intracoronary thrombolytics (tenecteplase) in complex PCI after the onset of thrombotic complications is safe and may even improve the success rate in PCI complicated by thrombus in the study of 34 patients (22 with acute ST elevation MI, 4 with rescue PCI, 6 with non-ST elevation MI, and 2 during elective PCI) 11) . Additionally Hara et al demonstrated in their report that the incidence of noreflow was lower and the angiographical success rate was higher for thrombolysis than angioplasty in acute myocardial infarction patients with thrombus-rich lesions 12) .…”

A case of successful reperfusion through a combination of intracoronary thrombolysis and aspiration thrombectomy in ST-segment elevation myocardial infarction associated with an ectatic coronary artery

“…In recent years, intracoronary thrombolysis has regained popularity as an adjuvant therapy for primary PCI, as studies using different thrombolytic agents and improved antiplatelet regimens showed it to be safe and effective. Kelly et al [12] reported that intracoronary infusion of tenecteplase was safe and effective for coronary flow recovery in patients with myocardial infarction. More recently, Boscarelli et al [13] found that adjuvant intracoronary infusion of low dose tenecteplase and alteplase in STEMI significantly reduced the thrombi remaining after MAT and improved coronary blood flow.…”

Intracoronary pharmacotherapy in the management of coronary microvascular dysfunction

“…Kelly et al [71] demonstrated that TNK-supported PCI significantly improved the no reflow phenomenon in these patients. IC tPA was studied by Abbas et al in the setting of recanalization for chronic total occlusion among patients with progressive symptoms in whom prior attempts failed.…”