A 37-year-old man presented with worsening chest pain and positive severe acute respiratory syndrome coronavirus 2 assay with blood pressure of 80/40 mm Hg. Electrocardiography showed diffuse ST-segment elevation. Right-heart catheterization revealed a cardiac power index of 0.3 W/m2 and normal pulmonary artery pulsatility index. After an Impella CP (Abiomed, Danvers, Massachusetts) was placed, coronary angiography demonstrated large thrombus burden in the distal left main coronary artery with complete occlusion of ostial left anterior descending artery (LAD) and ramus intermedius and partial occlusion of the left circumflex artery (LCx) (Figure 1A ). After heparin and cangrelor were initiated, percutaneous coronary intervention with the STRIATE-G (Stent RetRIever and Aspiration ThrombEctomy from Guide catheter) technique was planned. Using an 8-F Extra-backup 3.5 guide catheter (Cordis, Hialeah, Florida), a 0.014-inch Cougar guidewire (Medtronic, Minneapolis, Minnesota) was advanced past the lesion into the LCx, followed by advancement of a Terumo MicroVention Headway-27 microcatheter (MicroVention, Aliso Viejo, California). The guidewire was then removed, and a Solitaire 6.0/40-mm Platinum stent retriever (SR) (Medtronic) was advanced through the microcatheter into the LCx. Next, the microcatheter was pulled back into the guide to “unsheath” and deploy the SR (Figure 1B). The guiding catheter’s injecting port was attached to the Penumbra aspiration pump (Penumbra, Alameda, California) (Figures 1C and 1D). After 3-min dwell time with the SR fully deployed, the Penumbra was activated to initiate aspiration, and the SR was pulled back into the guiding catheter. A similar technique was applied in the LAD (Figure 1E).
Figure 1.
The STRIATE-G (Stent RetRIever and Aspiration ThrombEctomy From Guide Catheter) Technique for Large Thrombus Burden and COVID-19 ST-Segment Elevation Myocardial Infarction
(A) Angiogram showing thrombus burden in left main coronary artery (LMCA), left anterior descending artery (LAD), and ostial left circumflex artery (CIRC). (B) Stent retriever deployed in the CIRC. (C, D) Injecting port of the guide catheter attached to the Penumbra aspiration pump. (E) Stent retriever deployed in the LAD. (F) Final angiogram showing Thrombolysis In Myocardial Infarction flow grade 3 with no residual thrombus.
Afterward, intravascular ultrasound demonstrated a minimal laminar clot in the LAD without significant atherosclerosis. Final angiography showed Thrombolysis in Myocardial Infarction flow grade 3 with no residual thrombus (Figure 1F). The patient was transferred to the intensive care unit for further management. This is the first reported case of the STRIATE-G technique to date and is different from a previous report (1) in which the operators advanced an SR microcatheter or Penumbra microcatheter distally and aspirated the clot directly from the SR. The major risk of using an SR in the coronaries is the embolization of clot and debris into the aorta because of disproportionate guide and left main size and possible embolization into the LCx as one pulls the SR out from the LAD. This can be mitigated by connecting the aspiration pump port directly to the guiding catheter port and performing continuous suction simultaneously as the SR is being retrieved into the guide.
Funding Support and Author Disclosures
Dr. Khan has served as a proctor for Edwards Lifesciences and Medtronic. Dr. Waksman has served on the advisory board for Amgen, Boston Scientific, Cardioset, Cardiovascular Systems, Medtronic, Philips, and Pi-Cardia; has served as a consultant for Amgen, Biotronik, Boston Scientific, Cardioset, Cardiovascular Systems, Medtronic, Philips, and Pi-Cardia; has received grant support from AstraZeneca, Biotronik, Boston Scientific, and Chiesi; has served on the Speakers Bureau for AstraZeneca and Chiesi; and is an investor in MedAlliance. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Reference
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