Case 156: Manual of PCI - Large thrombus

A patient presented with an inferior STEMI and was found to have complete occlusion of a large dominant RCA. Diagnostic angiography was performed through right radial access but guide engagement was very challenging due to subclavian tortuosity. An AL1 and Ikari Right guide catheters kinked. Femoral access was obtained, but still engagement was challenging, and guide support was poor. After inserting a 45 cm long sheath and upsizing to a 7 French JR4 guide we successfully wired the RCA restoring TIMI 1 flow. Despite multiple passes with the Penumbra catheter, large thrombus remained within the RCA. We inserted a 6 French Guideliner Coast into the RCA and did aspiration through the side port of the tuohy removing several large thrombi. We then stented, that resulted in no reflow. Flow improved after intracoronary eptifibatide and nicardipine, that were given through the Penumbra catheter. We did IVUS and decided to not perform postdilatation to minimize the risk of recurrent distal embolization. The patient had an uneventful recovery.

[@shangz0216]

Thanks for the educative case presentation.

[@yasseralmayali7680]

Perfect 👍

[@amrhanafymahmoud9829]

Perfect

[@erdi044]

Dear Brilakis, we follow your posts with interest. In our clinic, we use the Sofia aspiration catheter in ectatic cases with high thrombus burden (especially in the right coronary artery) and the results are quite satisfactory.

[@manosbrilakis]

Thank you, great point.

[@moatazzaki5977]

What do you think of pre emptive ic verapamil before stenting so as to prepare microvasculature for possible embolization post stenting?

[@DAF57092]

Excellent case! Thoughts on Angiojet for this case?

[@Docsammy]

In a stemi obviously switching to femoral access quickly is right thing. For subclavian tortuosity, i sometimes use a 75cm Terumo destination sheath which allows engagement. 6F guide will fit 6F destination sheath.

[@serhatgunlu6669]

try to use infinity 90 cmsheath

[@diansetiawan9541]

What your opinion, if we use Ikary left with long sheat from femoral access (after coronary angiography). Btw very Excellent case.. Thank you so much

[@manosbrilakis]

That would likely work, thanks for your comment!

[@farukakturk5388]

Is post dilatation or high pressure deployment necessary in stemı? Restoreing tımı 3 flow and post dilatation can be an option. What is your strategy?

[@manosbrilakis]

I think that high pressure balloon inflation should probably be avoided in STEMI due to risk of distal embolization (except in balloon undilatable lesions).

[@yildirimyildirim9558]

In the presence of dense thrombus, better results are obtained if clotinab is given before the balloon. What do you think about this issue?

[@manosbrilakis]

Abciximab is not available in the US anymore, but it can help reduce thrombus burden and improve flow.

[@Prasannakumar-jl8pi]

What about local thrombolysis with low dose tenecteplase

[@NikhilJha89]

What about Giving eptifibatide 48 hours and bring back patient?

[@manosbrilakis]

Great point - we typically do this if we have TIMI 3 flow - antegrade flow was not very good after thrombectomy in this case and the patient had persistent ST elevation