CASE 14 Extensive Coronary Thrombus
Cardiac catheterization
The patient arrived in the cardiac catheterization laboratory approximately 2 hours after receiving thrombolysis. As expected, the right coronary artery was completely occluded (Figure 14-1). There was no significant obstructive disease noted in the left coronary arteries. An additional intravenous bolus of enoxaparin was administered, along with a bolus plus infusion of eptifibatide. The operator inserted a guide catheter and easily passed a 0.014 inch floppy-tipped guidewire to the distal artery. A 2.5 mm by 20 mm long compliant balloon inflated at the occlusion site immediately restored TIMI-3 flow, and resulted in resolution of chest pain and ST-segment elevation. However, an extensive filling defect was observed, consistent with a large intracoronary thrombus (Figure 14-2 and Video 14-1). The operator passed a Pronto extraction catheter over the floppy-tipped guidewire to the distal artery and, using a 30 cc syringe, gently aspirated as the catheter was withdrawn to the guide catheter. A large amount of clot was successfully removed and improved the angiographic appearance of the artery with no evidence of distal embolization (Figure 14-3 and Video 14-2). A 4 mm diameter by 28 mm long bare-metal stent postdilated with a 4.5 mm noncompliant balloon successfully treated the residual stenosis (Figures 14-4, 14-5 and Video 14-3). At the completion of the procedure, the patient had no further chest pain and was transferred to the coronary care unit.
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