Abstract
We described a case of successful stentless percutaneous coronary intervention (PCI) with Thrombolysis in Myocardial Infarction (TIMI) 3 flow in the right coronary artery (RCA) with diffuse large thrombus, and an algorithm of PCI strategy for the cases with similar clinical scenarios in the current PCI era. Theoretically, stentless PCI might be superior to PCI using a stent since it may prevent long-term issues of dual antiplatelet therapy, stent fracture, and stent thrombosis. In particular acute coronary syndrome with diffuse large thrombus in the RCA will make multiple stenting necessary which may be associated with worse outcomes due to distal coronary flow disorder. We present a case that illustrates that stentless PCI is successful in this scenario. Further research in this field is warranted.
Highlights
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ACS with large thrombus is still an issue due to distal embolism and slow flow/no reflow.
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Stentless PCI is an advisable strategy to prevent myocardial injury in ACS.
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Short term warfarin therapy might be effective to resolve diffuse thrombus in ACS.
1
Introduction
Over the past two decades, the devices of percutaneous coronary intervention (PCI) have evolved, resulting in better patient outcome particularly regarding the treatment of acute coronary syndrome (ACS). In general, stents have been used for primary PCI in the current era. In patients with diffuse large thrombus, we sometimes need to perform multiple stenting. ACS with diffuse large thrombus remains an issue in the PCI field because it could easily induce slow flow/no reflow (SF/NR) phenomenon and distal embolism [ ]. SF/NR is associated with adverse outcomes in ACS [ ]. We report a successful case of diffuse large thrombus in a patient with ACS in the right coronary artery (RCA) without stent usage.
2
Case description
A 45-year-old male was admitted due to ACS. An emergency coronary angiogram revealed an RCA with a long occlusion which has Rentrop grade 3 collateral from left coronary artery ( Fig. 1 , Aa and Ab). Large red thrombi were removed with frequent passes of 7Fr aspiration catheter. Due to the residual large thrombus, intracoronary thrombolysis (urokinase 120,000 U) following 3.0 mm ballooning with distal protection (Filtrap TM , Nipro, Osaka, Japan) resulted in almost Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 ( Fig. 1 B and Video 1 ). Intravascular ultrasound (IVUS) imaging showed diffuse large thrombus in the RCA and distal segment rupture with 50% plaque ( Fig. 1 , Da), but there was not significant plaque and/or dissection in other segments ( Fig. 1 , Db and Dc, and Video 2 ). Therefore we thought that the very focal plaque rupture was the only culprit lesion ( Fig. 1 , blue arrows) and avoided stenting mostly due to the widespread presence of the thrombus in a long segment of the RCA. After 2 weeks of antiplatelet therapy with aspirin and anticoagulation with warfarin, a new coronary angiogram showed that the thrombus disappeared with complete restoration of TIMI flow grade 3 ( Fig. 1 C and Video 3 ). Maximum creatine kinase MB was 5-ng/ml, and cardiac scintigraphy showed retained myocardial viability ( Fig. 1 E). Coronary artery computed tomography (CT) at 9 month follow-up showed 25% plaque and large lumen at distal RCA with sufficient coronary flow ( Fig. 1 , F and G).
2
Case description
A 45-year-old male was admitted due to ACS. An emergency coronary angiogram revealed an RCA with a long occlusion which has Rentrop grade 3 collateral from left coronary artery ( Fig. 1 , Aa and Ab). Large red thrombi were removed with frequent passes of 7Fr aspiration catheter. Due to the residual large thrombus, intracoronary thrombolysis (urokinase 120,000 U) following 3.0 mm ballooning with distal protection (Filtrap TM , Nipro, Osaka, Japan) resulted in almost Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 ( Fig. 1 B and Video 1 ). Intravascular ultrasound (IVUS) imaging showed diffuse large thrombus in the RCA and distal segment rupture with 50% plaque ( Fig. 1 , Da), but there was not significant plaque and/or dissection in other segments ( Fig. 1 , Db and Dc, and Video 2 ). Therefore we thought that the very focal plaque rupture was the only culprit lesion ( Fig. 1 , blue arrows) and avoided stenting mostly due to the widespread presence of the thrombus in a long segment of the RCA. After 2 weeks of antiplatelet therapy with aspirin and anticoagulation with warfarin, a new coronary angiogram showed that the thrombus disappeared with complete restoration of TIMI flow grade 3 ( Fig. 1 C and Video 3 ). Maximum creatine kinase MB was 5-ng/ml, and cardiac scintigraphy showed retained myocardial viability ( Fig. 1 E). Coronary artery computed tomography (CT) at 9 month follow-up showed 25% plaque and large lumen at distal RCA with sufficient coronary flow ( Fig. 1 , F and G).
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