Abstract
The management of coronary thrombus is not well defined. Current therapies include medical management with anticoagulation, antiplatelet, and thrombolytic therapies or revascularization with percutaneous coronary interventions including mechanical thrombectomy, and coronary artery bypass grafting surgery. In this report, we present a patient with significant left main coronary artery thrombus burden with advanced cirrhosis and recent esophageal variceal bleeding who was successfully treated with conservative medical management.
Highlights
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Management of each patient with coronary thrombus should be individualized.
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Significant improvement of left main thrombus can be achieved with heparin and dual antiplatelet therapy.
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Intracoronary imaging will help identify the thrombus burden and guide correct management.
1
Introduction
Coronary artery disease (CAD) is a leading cause of death worldwide [ ]. Left main coronary artery thrombus is a rare event accounting for approximately 0.8–1.7% of patients presenting with unstable angina, NSTEMI, and STEMI [ ]. Currently, guidelines and recommendations exists for the management of acute coronary syndrome, however, there is limited data regarding optimal management of acute left main coronary artery thrombus.
2
Case presentation
A 67-year-old man with paroxysmal atrial fibrillation, liver cirrhosis, portal vein thrombosis, and hepatocellular carcinoma presented to our hospital with acute shortness of breath and chest pain. He was recently admitted for upper gastrointestinal bleed and treated with packed red blood cell transfusions and esophageal variceal banding. His home anticoagulation therapy (lovenox) was held at discharge until further follow up. Examination was remarkable for jaundice and ascites. Troponin I was elevated at 2 ng/ml, and anterolateral T-wave inversions were present on a 12‑lead electrocardiogram ( Fig. 1 ). Transthoracic echocardiogram showed normal left ventricular function without any regional wall motion abnormalities and no valvular heart disease. He was loaded with aspirin and underwent coronary angiogram which revealed calcified coronary artery aneurysms with large mobile mural thrombus in the left main (LM) coronary artery with Thrombolysis In Myocardial Infarction (TIMI) 3 flow ( Fig. 2 ). Given his left main aneurysm with non-obstructed flow and recent bleeding, we opted for medical management in the intensive care unit with therapeutic heparin and aspirin therapy. A repeat angiogram and intravascular ultrasound (IVUS) after 72 h revealed a significant improvement to a small non-obstructive mural LM thrombus. Mid left anterior descending artery (LAD) showed 90% stenotic lesion ( Fig. 3 ). A 3.5 × 22 mm Integrity bare metal stent (BMS) was deployed across the mid LAD lesion. He was discharged home on dual antiplatelet therapy (aspirin and clopidogrel) for one month and long term anticoagulation with subcutaneous lovenox given his advanced liver disease. The patient had a follow up visit after 3 months with no recurrent chest pain or bleeding issues.
