Modified revisiting of old balloon inflation technique during PCI for dealing with thrombus laden lesion in non-ST-segment elevation myocardial infarction

Current European and U.S. guidelines recommend manual thrombectomy in patients with STEMI.¹ However, in non-ST-segment elevation myocardial infarction (NSTEMI), ∼50–70% of all patients also display relevant thrombus burden in the culprit vessel.² Furthermore, with rates of angiographic no-reflow ranging from 15% to 40% depending on thrombus burden and intraprocedural thrombotic events, in a significant portion of patients with NSTEMI, only suboptimal reperfusion success can be achieved.³ Thus, thrombectomy in patients with NSTEMI may represent a useful intervention with the potential to reduce myocardial damage and improve patient prognosis. Due to a lack of data, current guidelines do not give a clear recommendation for thrombus aspiration in NSTEMI.⁴

A male patient, 37 years old, obese, hypertensive, dyslipidemic and diabetic, presented with typical exertional retro-sternal chest pain since 1 month, pain relieved with rest and nitro-glycerin. The patient had previous PCI with DES in LAD and BMS in distal RCA 18 months ago. ECG showed ST depression in II, III, and avf. Echo showed mid, apical inferior and basal septal wall hypokinesia, cardiac troponin, and CK-MB were positive. Coronary angiography showed patent stent in LAD. Distal RCA was seen filling retrogradely from distal LAD. RCA showed a highly thrombus laden lesion very proximal to the ostium with no antegrade filling. The patient was loaded with 10,000 IU unfractionated heparin and 300 mg of Clopidogrel. RCA was cannulated with JR4 GC; PT2 MS GW was used to cross the lesion lying eccentically in the artery. Aspiration was tried several times but failed to produce any thrombus materials. IC tirofiban was given in recommended dose, and pre-dilatation was done using up escalating balloon dilatation with low pressure so as to deform the geometry of the thrombus without crushing it in a special way. Then, trapping of the residual thrombus was done by stent deployments, 2DES, Xience v 3.5*38 distally across the previous stent and another Xience v 3.5*33 overlapping the first stent. Finally, post-dilatation was carried out with non-compliant balloon, achieving a successful TIMI 3 flow.

1. Discussion

The majority of patients with NSTEMI demonstrate some thrombus burden or even occluded coronary arteries and thus might benefit from thrombectomy.² Nevertheless, current guidelines do not recommend thrombus aspiration in NSTEMI patients.4, 5

However, in the most recently published trial of the TATORT-NSTEMI, the authors concluded that Manual aspiration thrombectomy in patients with thrombus-containing lesions do not reduce the extent of no-reflow compared with standard PCI as measured by microvascular obstruction (cardiac magnetic resonance). These findings are supported by a lack of benefit in angiographic, enzymatic, and clinical secondary endpoints.⁶

Here in my case, thrombus aspiration was done but nothing was obtained, IC tirofiban was given in an attempt to lessen the proximal load of the thrombus as well as to get it down away from the ostium to reduce the risk of retrograde aortic embolization.

1.1. My strategy of PCI

Two main issues were addressed:

• (1)Achieving immediate revascularization.
• (2)
  Avoiding complications which may adversely affect the outcome.

  • (a)
    Retrograde aortic embolization.
  • (b)
    Antegrade distal coronary embolization with defective microvascular perfusion.

1.2. Technical steps of PCI procedure

• (1)GP IIb/IIIa intracoronary injection to take care of the freshest superficial thrombosis (Fig. 1).
• (2)GP IIb/IIIa intravenous continuous infusion for 24–48 h as a downstream therapy.
• (3)Small-sized balloon, low-pressure inflation (to deform the thrombus geometry to be more axially aligned without crushing it) (Fig. 2).
• (4)Bigger-sized balloon, low-pressure inflation (to create pass for stent tracking without pushing down thrombus or crushing it) (Fig. 2).
• (5)Balloon dilatation through the closed stent was done as a last step before stent deployment using it as a valve for crushing the thrombus to vessel wall but not allowing the thrombus fragments to wash out distally (Fig. 3).
• (6)Thrombus trapping by stents (between stent struts and vessel lumen) (Fig. 3).

Fig. 1.

Steps of procedural intervention: (a) LAD with patent stent gives off retrograde epicardial collaterals to distal RCA. (b) RCA lesion with high burden of thrombosis. (c) Successful wiring of RCA eccentric course. (d) Washout of the proximal part of the thrombus.

Fig. 2.

Steps of procedural intervention: (e, f) low-pressure small-sized balloon inflation. (g) Low-pressure bigger balloon inflation. (h) RCA with opened tract with visible thrombus.

Fig. 3.

Steps of procedural intervention: (i–l) stent deployments with trapping thrombus residue in-between stents and vessel lumen. (m, n) TIMI III flow through RCA.

2. Conclusion

Thrombus containing lesions could be treated with simple workhorse tools in an innovative modification with accepted results and least complications.

Conflicts of interest

The author has none to declare.