Abstract
Primary percutaneous intervention of saphenous vein grafts is associated with a high risk of distal embolization and no reflow. We report a case of acute myocardial infarction with a large intragraft thrombus, successfully treated with a technique combining thrombectomy with a 6 Fr guiding catheter and distal protection with the FilterWire EZ.
1
Introduction
Primary percutaneous coronary intervention (PCI) of saphenous vein graft (SVG) lesions with a large thrombus load is associated with a high risk of distal embolization and no-reflow . Therefore, in deciding on the best protection strategy, it is important to consider specific lesion and vessel characteristics, as well as thrombus burden. We report a case of acute myocardial infarction (AMI) in which emergent angiography demonstrated a large thrombus in a SVG. The combination of manual thrombosuction with the guiding catheter and distal protection with the filterWire EZ resulted in immediate resolution of chest pain, electrocardiographic changes and normalization of TIMI flow.
2
Case report
A 48-year-old man presented to the emergency department 2 h after onset of severe chest pain. He had a past medical history of coronary artery bypass graft surgery 7 years before, with left internal mammary artery (LIMA) to the left anterior descending artery (LAD), and saphenous vein grafts (SVG) to an obtuse marginal branch and to the right posterior descending artery (RPDA). Since the ST segment was elevated in leads II, III and aVF, a diagnosis of inferior AMI was made. The patient was premedicated with aspirin, clopidogrel, intravenous unfractionated heparin and abciximab, and transferred for emergent angiography.
Angiography showed a patent LIMA graft to the LAD. The native LAD was totally occluded after the first diagonal branch. The native left circumflex had a 70% proximal stenosis, and a SVG to the first marginal branch was patent. The native RCA was totally occluded. The culprit lesion was identified in the SVG to the RPDA, which presented a large filling defect in its mid portion and TIMI-II flow ( Fig. 1 A ). The SVG was engaged with a soft-tip multipurpose guiding catheter (Cordis) and initially wired with a 0.014” Hi-torque Balance Middleweight guidewire (Guidant). Since the catheter fit well and aligned straight in the graft, it was slowly advanced over the wire to the distal portion of the graft ( Fig. 1 B). The wire was then removed and, mantaining constant negative suction, the guiding catheter was slowly withdrawn from the SVG and out of the femoral sheath. Flushing the guiding catheter revealed a large thrombus that matched the filling defect ( Fig. 2 ). This thrombosuction resulted in immediate resolution of chest pain and electrocardiographic changes. The guiding catheter was reinserted and angiography revealed a patent graft with TIMI-III flow, and evidence of very small filling defects suggestive of residual thrombotic material ( Fig. 3 A ; arrows). Due to concerns about the development of no-reflow we recrossed the lesion using a FilterWire EZ (Boston Scientific) before stenting ( Fig. 3 B; arrow). A 4 × 20 mm Taxus-Liberte stent (Boston Scientific) was then implanted to treat the index lesion. Following stent deployment, angiography revealed full stent expansion, no residual stenosis, but slow-flow in the graft suggesting distal embolization of the residual thrombotic material. The filterWire EZ was then removed and final angiography showed a successful angiographic result and TIMI-III flow into the distal SVG-RPDA ( Fig. 4 ). Visual inspection of the retrieved filter revealed few small pieces of thrombus. The patient had an uneventful post-procedural course and is free of symptoms after 2 years of follow-up.
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