Editor's note: View video accompanying this article.
Abstract: Angiographically visible thrombus and distal embolization are relatively common during percutaneous coronary intervention (PCI) in myocardial infarction (MI) and correspond to worse outcomes. Several aspiration and thrombectomy devices have been shown to be effective for prevention of distal embolization. We present a technique with successful use of the GuideLiner catheter (Vascular Solutions) for thrombus aspiration after dedicated manual aspiration thrombectomy devices have failed. Our case series includes large thrombus burden in clinical scenarios of ST-elevation MI in a native vessel, non-ST elevation MI in a vein graft, and ST-elevation MI due to native vessel in stent thrombosis.
J INVASIVE CARDIOL 2013;25(11):620-624
Key words: aspiration thrombectomy, myocardial infarction
Primary percutaneous coronary intervention (PCI) usually establishes normal or near-normal antegrade blood flow, in over 90% of cases.1 Less than Thrombolysis in Myocardial Infarction (TIMI)-3 flow is associated with worse outcomes.2 Distal embolization and “no-reflow” phenomenon are important causes of suboptimal reperfusion after primary PCI in ST-elevation myocardial infarction (STEMI).2-4 Recent studies have advocated routine use of thrombus aspiration devices in patients with acute coronary syndromes (ACS), particularly STEMI. This strategy has been shown in some studies to improve overall outcome in STEMI.5 Several thrombectomy devices are available in the United States, including Diver (Invatec), Export (Medtronic), Probing (Boston Scientific), Pronto (Vascular Solutions), and Rescue catheters (Boston Scientific).6-9
We present a technique for novel application of the GuideLiner (GL) catheter for intracoronary thrombus aspiration in 3 cases of ACS, in which a dedicated coronary aspiration catheter has failed to sufficiently reduce the thrombus burden. Our GL technique resulted in complete angiographic thrombus disappearance and normal flow restoration in all cases.
The GL was advanced over a guidewire with its distal tip positioned a few millimeters proximal to the coronary thrombus. An Export catheter aspiration syringe was attached to the stopcock on the side port of the Y-connector used routinely for PCI. The valve on the Y-connector was tightened enough to have a good seal around the guidewire and the GL push rod so that there was no air leak during the aspiration, but the GL could be moved at the same time. The aspiration syringe was locked in vacuum position with the stopcock closed toward the syringe. Then, the stopcock was turned to open position between the syringe and the guide catheter with advancement of the GL into the thrombus. Brisk flow was obtained into the syringe. One syringe aspiration was done for passing the thrombotic vessel segment. Another aspiration in the same fashion was performed on withdrawal of the GL across the involved segment. Once the GL was completely back in the guide catheter, its tip pressure wave and Y connector were inspected for evidence of thrombus in the system before further intervention.
A 50-year-old male presented with inferior STEMI. Emergent catheterization showed proximal right coronary artery (RCA) 100% thrombotic occlusion and non-obstructive disease of the left coronary system (Figure 1). The patient received aspirin 325 mg, heparin bolus prior to the catheterization laboratory, and an eptifibatide drip in the catheterization lab. The lesion was crossed easily with a guidewire and predilated with a 2 x 15 mm balloon, restoring TIMI-2 flow. Due to high thrombus burden (Figure 2), an Export catheter was used and thrombus aspiration was performed. Despite multiple passes and thrombus retrieval evidence in the aspirate, the flow stopped and “no-reflow” phenomenon persisted, although intracoronary adenosine was given (Figure 3; Video 1). A 6 Fr GL (in 6 Fr guide) was inserted into the proximal part of the RCA and aspiration thrombectomy was performed. A large amount of clot was aspirated, with restoration of TIMI-3 flow (Figure 4; Video 2). The thrombus volume retrieved via GL aspiration was significantly larger than the thrombus recovered from the initial Export catheter aspiration (Figure 5). A drug-eluting stent was deployed with good angiographic result (Figure 6) and the patient had an uneventful hospital course.
An 87-year-old male with a history of coronary artery bypass surgery presented with non-ST elevation myocardial infarction (NSTEMI). The patient was on aspirin 325 mg and bivalirudin was initiated for the PCI. Angiography showed the culprit lesion in the saphenous venous graft (SVG) to the obtuse marginal branch (Figure 7). It was predilated with a 2 x 15 mm balloon and stented. After stenting, there was evidence of no re-flow, for which intravascular adenosine was given, and then Export catheter thrombectomy was performed. However, no re-flow persisted. A mobile mass consistent with thrombus was noted in the SVG (Figure 8). The GL aspiration technique was applied with a large amount of clot retrieval. Normal flow was restored in the vessel with disappearance of the previously noted thrombus (Figure 9). The patient did well after PCI.
A 55-year-old male with a history of MIs and PCI presented with inferior STEMI. Aspirin 325 mg was given in the emergency room and bivalirudin was initiated in the catheterization laboratory. Emergent catheterization showed proximal RCA thrombotic in-stent occlusion and non-obstructive disease of the left coronary system (Figure 10). The lesion was predilated with a 2.5 x 15 mm balloon and Export catheter thrombectomy was performed. Thrombus persisted near the stented segment in spite of multiple passes (Figure 11). GL thrombectomy resulted in clot retrieval and normal flow restoration, as well as angiographic disappearance of the thrombus. The vessel was stented with good result (Figure 12) and the patient did well afterward.
An ideal aspiration catheter should be easy to work with, deliverable and safe, and its lumen should be large enough for full thrombus aspiration. Based on internal lumen diameter, aspiration catheters can be divided into three groups: large (Diver, 0.062˝; Pronto, 0.065˝), medium (Export, 0.041˝; Rescue, 0.042˝), and small (Probing, 0.018˝). At present, it not proven whether large-diameter coronary catheters are able to aspirate larger thrombotic components when compared with smaller ones. Retrieval of larger particles by larger lumen catheters potentially could improve the myocardial perfusion after PCI. On the other hand, a larger lumen diameter could influence handling characteristics and device safety.10
The GL is a 25 cm guide extension connected to a rapid-exchange push rod by collar transition. It has been used primarily in complex coronary angioplasties for extra support, selective contrast delivery, and protected distal stent delivery and deployment.11,12
We used 6 Fr GL with same guide size for manual aspiration thrombectomy. In our series of acute MI patients, the GL has proven superior to the Export catheter regarding the amount and completeness of thrombus retrieval. Our GL technique was easy to apply.
The internal diameter and cross-sectional area of a 6 Fr GL are significantly greater than that of the Export catheter. The internal diameter of a 6 Fr GL catheter is 0.056˝ (1.42 mm), which corresponds to a cross-sectional area of 1.48 mm2 (after subtracting the area of guidewire). The internal diameter of Export catheter is 0.041˝ (1.016 mm), which corresponds to a cross-sectional area of only 0.81 mm2. Thus, the cross-sectional area of the GL is almost double that of the Export catheter. The Pronto V3 aspiration catheter is larger than Export, but its cross-sectional area (0.93 mm2) is still smaller than that of the GL (Figure 13). The dedicated aspiration catheters have tips modified for improvement of flow characteristics and safety; however, the GL round atraumatic tip can symmetrically aspirate thrombus and adapt to the vessel. It has been demonstrated that the main factor for successful thrombus aspiration is internal diameter of the aspiration catheter and actually straight tip catheter works better than beveled tip.13
As per Poiseuille’s law, radius has a major impact on the rate of flow of fluid through a tube (Q = π x r4 x (ΔP) / 8 x n x L, where Q = flow rate, r = radius, P = pressure, n = viscosity, and L = length). Thus, a small increase in radius dramatically increases the flow rate through a tube, which we have witnessed comparing the GL versus Export flow in all of our cases. Also, the length of our GL aspiration system is shorter than in dedicated aspiration catheters, having positive impact on flow (L in the equation). Thus, since the GL can maintain higher flow than the current dedicated coronary aspiration catheters, we were able to aspirate larger thrombus compared to the Export (Figure 5) and GL worked well in our cases after Export failed.
The GL aspiration technique involves suction from the syringe transmitted directly into the guide catheter and then into the GL lumen. The small potential space between the external lumen of the GL and the internal lumen of the guide catheter seems to have no negative effect on the aspiration, as we have noticed a very rapid and pulsatile inflow into the syringe with this system. A matched size of GL to guide catheter seems to be reasonable, since smaller GL than guide size could result in decrease in suction force on the GL tip due to potential flow in between both catheter walls. In our system, the thrombus travels mostly through the guide catheter’s large lumen (with a short distance of 25 cm inside the comparatively smaller GL lumen), which is also beneficial for thrombus removal. In dedicated coronary aspiration catheters, the thrombus travels through their long lumens (over 100 cm long, since they need to be longer than guide catheters) without the benefit of the large lumen of the guide catheter for thrombus transportation and exporting.
Although the external diameter of the GL catheter is larger than in coronary aspiration catheters, the GL catheter tip is quite soft and flexible, allowing for atraumatic deep intubation of coronary arteries and grafts. Previously, the “mother and child” technique of using smaller diagnostic catheters within guide catheters has been described for aspiration thrombectomy; in our opinion, using a GL is safer because the tip and body of the GL are softer than in diagnostic catheters.14 In all cases presented here, various other options including AngioJet catheter, other manual aspiration catheters, and intracoronary t-PA were considered. However, due to the lack of convincing literature for the benefits of these devices, we decided to use the GL catheter for aspiration thrombectomy instead.15,16 The angiographic appearance of the vessels after stenting and removal of the GL were excellent at the end of our cases. Since there was no suspicion of vessel injury, we did not perform intravascular ultrasound or optical coherence tomography.
We propose the GL catheter as an alternative to dedicated coronary aspiration devices for thrombus removal in acute MI, especially in large vessels and in proximal thrombus locations. The GL can also be beneficial in stent delivery after successful thrombus removal in challenging coronary anatomy cases. Ideally, a randomized trial would be needed comparing GL to coronary aspiration catheters to prove its superiority in thrombus removal. Possibly, such a trial could also show benefits in clinical outcomes since potentially greater thrombus burden decreases could translate into better clinical outcomes.
To the best of our knowledge, this is the first description of the GL technique for coronary thrombus aspiration in the medical literature.
We illustrate the safe and effective use of GL for manual aspiration thrombectomy with good angiographic results. This is another potential use of this versatile catheter which is classically used for extra support for equipment delivery in complex interventions.
- Mehta RH, Harjai KJ, Cox D, et al. Clinical and angiographic correlates and outcomes of suboptimal coronary flow inpatients with acute myocardial infarction undergoing primary percutaneous coronary intervention. J Am Coll Cardiol. 2003;42(10):1739-1746.
- Ito H, Maruyama A, Iwakura K, et al. Clinical implications of the ‘no reflow’ phenomenon: a predictor of complications and left ventricular remodeling in reperfused anterior wall myocardial infarction. Circulation. 1996;93(2):223-228.
- Rezkalla SH, Kloner RA. No-reflow phenomenon. Circulation. 2002;105(5):656-662.
- Henriques J, Zijlstra F, Ottervanger J, et al. Incidence and clinical significance of distal embolization during primary angioplasty for acute myocardial infarction. Eur Heart J. 2002;23(14):1112-1117.
- De Luca G, Suryapranata H, Stone GW, Antoniucci D, Neumann FJ, Chiariello M. Adjunctive mechanical devices to prevent distal embolization in patients undergoing mechanical revascularization for acute myocardial infarction: a meta-analysis of randomized trials. Am Heart J. 2007;153(3):343-353.
- Svilaas T, Vlaar PJ, van der Horst IC, et al. Thrombus aspiration during primary percutaneous coronary intervention. N Engl J Med. 2008;358(6):557-567.
- Silva-Orrego P, Colombo P, Bigi R, et al. Thrombus aspiration before primary angioplasty improves myocardial reperfusion in acute myocardial infarction: the DEAR-MI (dethrombosis to enhance acute reperfusion in myocardial infarction) study. J Am Coll Cardiol. 2006;48(8):1552-1559.
- Burzotta F, Trani C, Romagnoli E, et al. Manual thrombus-aspiration improves myocardial reperfusion: the randomized evaluation of the effect of mechanical reduction of distal embolization by thrombus-aspiration in primary and rescue angioplasty (REMEDIA) trial. J Am Coll Cardiol. 2005;46(2):371-376.
- Kaltoft A, Bottcher M, Nielsen SS, et al. Routine thrombectomy in percutaneous coronary intervention for acute ST-segment-elevation myocardial infarction: a randomized, controlled trial. Circulation. 2006;114(1):40-47.
- Vlaar PJ, Svilaas T, Vogelzang M, et al. A comparison of 2 thrombus aspiration devices with histopathological analysis of retrieved material in patients presenting with ST-segment elevation myocardial infarction. JACC Cardiovasc Intervent. 2008;1(3):258-264.
- Cola C, Miranda F, Vaquerizo B, Fantuzzi A, Bruguera J. The Guideliner catheter for stent delivery in difficult cases: tips and tricks. J Interv Cardiol. 2011;24(5):450-461.
- Pershad A, Sein V, Laufer N. GuideLiner catheter facilitated PCI — a novel device with multiple applications. J Invasive Cardiol. 2011;23(11):E254-E259.
- Rioufol G, Collin B, Vincent-Martin M, et al. Large tube section is the key to successful coronary thrombus aspiration: findings of a standardized bench test. Catheter Cardiovasc Interv. 2006;67(2):254-257.
- Christian D, Araya M, Uriarte P, et al. ‘Mother-in-child’ thrombectomy technique: a novel and effective approach to decrease intracoronary thrombus burden in acute myocardial infarction. Cardiovasc Revasc Med. 2013;14(3):14-17.
- Migliorini A, Amerigo S, Alfredo ER, et al. Comparison of AngioJet rheolytic thrombectomy before direct infarct artery stenting with direct stenting alone in patients with acute myocardial infarction: the JETSTENT trial. J Am Coll Cardiol. 2010;56(16):1298-1306.
- Yusuf S, Collins R, Peto R, et al. Intravenous and intracoronary fibrinolytic therapy in acute myocardial infarction: overview of results on mortality, reinfarction and side-effects from 33 randomized controlled trials. Eur Heart J. 1985;6(7):556-585.
From the Department of Cardiovascular Diseases, Sanford Cardiovascular Institute, University of South Dakota, Sioux Falls, South Dakota.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted May 28, 2013, provisional acceptance given June 10, 2013, final version accepted July 2, 2013.
Address for correspondence: Naveen Rajpurohit, MD, Department of Cardiovascular diseases, Sanford Heart Hospital, 1400 West 22nd Street, Sioux Falls, SD 57105. Email: firstname.lastname@example.org