Refractory coronary embolus "trapped" and aspirated by a novel technique, EHJ case report

A large thrombus burden in patients with acute myocardial infarction is associated with worse outcomes. Although various methods of thrombus aspiration have been described, there is a potential limitation in the mechanism of eliminating a thrombus with only the use of an aspiration device. In a recent report published in European Heart Journal, investigators from Japan have described a novel method of retrieving massive thrombus using a guide extension catheter and a filter device.

An 80-year-old man was diagnosed with anterior ST-elevation myocardial infarction (STEMI). Emergency coronary angiography revealed that the left anterior descending artery (LAD) showed an acute thrombotic occlusion in the mid-section. The percutaneous coronary intervention was performed to recanalize an occluded LAD. Although thrombectomy using an aspiration catheter and a guide catheter extension system was performed repeatedly, only a small amount of the thrombus was retrieved, and the LAD was still occluded.

Therefore, interventionists Kusumoto et al planned to remove the large thrombus burden by capturing the entire thrombus between the tip of the guide extension catheter and distal protection device, followed by pulling them out of the guide catheter together. A large amount of red thrombus, which adhered to the axis of the filter device, was successfully retrieved. The occluded LAD was successfully recanalized without balloon dilatation or stent implantation. (Figure)

After the successful thrombus retrieval, intravascular ultrasonography (IVUS) catheter was inserted to examine the lesion morphology, and no ruptured atherosclerotic plaque was observed. The IVUS findings suggested that this STEMI event was caused by cardioembolism. The occluded LAD was successfully recanalized without balloon dilatation or stent implantation. Although follow-up echocardiography showed no evidence of cardiac thrombus formation, sufficient anticoagulant therapy was continued to avoid recurrent thromboembolism due to paroxysmal atrial fibrillation. Rivaroxaban 15 mg as an anticoagulant therapy was prescribed for 4 years. The anticoagulant drug was changed from Rivaroxaban 15 mg to warfarin 2 mg after PCI. The patient was discharged from the hospital 13 days after the procedure without any complications. At the 1-year follow-up visit, there has been no recurrence of thrombotic events.

The TASTE and TOTAL trials did not demonstrate any benefit of thrombus aspiration in clinical outcomes. Furthermore, TOTAL trial showed an increased risk of cerebral stroke. In the 2017 ESC guidelines for the management of STEMI patients, routine thrombus aspiration has been downgraded to a Class III recommendation. On the other hand, the TAPAS trial showed favourable findings in terms of cardiac death at one year in the thrombus aspiration group.

The actual report provides a few thrombectomy techniques, such as the mother-in-child thrombectomy technique and the thrombus aspiration catheter-assisted twisting wire technique in patients with AMI and a large thrombus burden undergoing PCI. However, sometimes large thrombi that cannot be retrieved by these techniques are encountered as there is a potential limitation in the mechanism of eliminating the thrombus with the aspiration device alone. To solve this problem, this novel technique combining a guide extension catheter and a filter device holds promise. This method is effective in removing refractory thrombi for the treatment of STEMI patients.

SOURCE: EHJ CASE REPORTS. Hirofumi K, Katsuyuki H, Kasumi et al, A novel treatment using a guide extension catheter and distal protection device for refractory coronary embolism: case report, European Heart Journal - Case Reports, Volume 5, Issue 1, January 2021, ytaa507, https://doi.org/10.1093/ehjcr/ytaa507