Thrombus Aspiration Complicated by Systemic Embolization in Patients With Acute Myocardial Infarction

Abstract

ercutaneous coronary intervention (PCI) is now the standard treatment for acute coronary syndrome (ACS). The optimal outcome of reperfusion treatment includes not only sustained patency of the epicardial coronary artery, but also optimal reperfusion of the myocardium throughout the microvasculature. It has been reported that in patients treated with primary PCI, distal embolization may be visualized on the coronary angiogram of 15.2% of such patients. 1 Embolization may occur spontaneously following plaque rupture, although mechanical crushing and fragmentation of the culprit lesion during PCI is reported to be the major cause of distal embolization. 2 In attempt to improve myocardial reperfusion following PCI, thrombus aspiration has emerged as a technique to prevent distal embolization [3][4][5][6] and has been demonstrated as effective in improving myocardial reperfusion. 7 Furthermore, it was shown recently to reduce the rate of 1-year cardiac mortality and nonfatal reinfarction. 8 However, the thrombus aspiration technique potentially may be complicated by systemic embolization, if the intracoronary thrombus is not completely aspirated by the guiding catheter and dislodges into the systemic circulation. We report 2 cases in which thrombus aspiration during PCI was complicated by systemic embolization. Case Reports Case 1A 70-year-old man with a history of coronary artery disease and hypertension was admitted to the Emergency Department (ED) because of inferior wall ST-elevation myocardial infarction (MI). Primary PCI was not undertaken because there had been a delay in arriving at the ED. He received aspirin 100 mg and clopidogrel 300 mg before PCI. Heparin was continuously infused and a bolus dose was given to keep the activated coagulation time (ACT) >300 s during the procedure. However, he experienced recurrent chest pain associated with high-degree atrioventricular block, so a temporary pacemaker was implanted and angiography was performed on day 3. It revealed total occlusion of the mid-right coronary artery (RCA) ( Figure 1A). PCI was performed using a 7Fr guiding catheter through the femoral approach. The angiogram taken immediately after ballooning revealed that the vessel was occluded at a more proximal portion, most likely because of migration of the huge thrombus ( Figure 1B). It was decided to remove the thrombus by aspiration using a Thrombuster catheter (Kaneka Corporation, Osaka, Japan, 7Fr), but contrast angiography revealed that the thrombus had migrated to the proximal RCA ( Figure 1C). The patient experienced transient loss of consciousness, followed by irritable mood and paralysis of the left limbs. The PCI was discontinued. A large infarction of the territory of the right middle cerebral artery was confirmed by cranial computed tomography. Case 2A 53-year-old woman with a history of hypertension and dyslipidemia, presented at the ED because of prolonged chest pain. Inferior-wall ST-elevation MI was diagnosed and she received aspirin 250 mg, clopidogrel 300 mg and intravenous heparin in...

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