Successful management of a huge thrombus in coronary aneurysmatic dilatation after failed mechanical thrombectomy during acute myocardial infarction

Abstract

The benefit of the routine application of aspiration thrombectomy in primary percutaneous coronary intervention (PPCI) is now well established. The optimal management of patients who have 'failed' thrombectomy, characterized by a large residual thrombus burden after repeated mechanical thrombectomy, however, is not known. We report a case of failed aspiration thrombectomy in a 55-year-old man who was admitted to our institution with chest pain non-ST-elevation myocardial infarction due to a huge nonocclusive thrombus in an aneurysmatic segment of the left anterior descending coronary artery. Aspiration thrombectomy did little to reduce thrombus load and so the patient was treated with unfractioned heparin infusion and warfarin. Repeat coronary angiography at 7 days revealed complete thrombus resolution with thrombolysis in myocardial infarction grade 3 anterograde flow.This case demonstrates the potential for appropriate anticoagulation therapy as a treatment option for the management of patients following failed thrombectomy in PPCI.

Coronary artery ectasia

“…Ielasi and Anzuini [49] described a good angiographic result after the use of unfractionated heparin in an ST elevation patient after failure of manual thrombectomy. Inaba et al [50] reported successful revascularization by pulse infusion of tissue plasminogen activator in a young patient with Kawasaki disease presenting with AMI.…”

Noninvasive In Vivo Coronary Artery Thrombus Imaging

“…Although there are no prospective studies investigating the time course of intracoronary thrombus resolution after myocardial infarction, case reports of serial coronary angiography confirm that the thrombus burden resolves over a few days (2 to 7 days) with administration of modern antiplatelet therapies including glycoprotein IIb/IIIa receptor antagonists. (33,34) In our study, imaging was performed between 5 and 31 days post myocardial infarction and delays in imaging beyond one week from the index event appears to have reduced the sensitivity of GP1 to identify intracoronary thrombus. Therefore, for diagnostic purposes, it should be performed within the first 7-10 days of acute myocardial infarction.…”

Successful intracoronary thrombolysis in a patient with anterior myocardial infarction and large thrombus burden associated with coronary artery ectasia

“…In such patients, who have a high thrombus burden, treatment modalities such as thrombo-aspiration and longterm heparin administration after thrombus aspiration have been used. 3,4 Given the high volume of thrombus and coronary ectasia, we used a combination of thrombo-aspiration and intracoronary thrombolysis, and continued heparin administration plus glycoprotein IIb/IIIa with a decent final result and no complication.…”

“…Our patient developed coronary artery occlusion with a high volume of thrombus in the LAD artery with coronary ectasia. In such patients, who have a high thrombus burden, treatment modalities such as thrombo‐aspiration and long‐term heparin administration after thrombus aspiration have been used 3,4 …”