Extensive thrombus in native coronary arteries is relatively rare. Percutaneous revascularization of thrombus-containing lesions has an increased incidence of adverse events, such as abrupt vessel closure and myocardial infarction. The two approaches to this problem are pharmacological treatment with thrombolytic agents or platelet glycoprotein IIb/IIIa blockers, or mechanical devices such as transluminal extraction atherectomy, rheolytic thrombectomy with Possis Angiojet and the Rescue Thrombectomy Catheter. Case Report.A 63-year-old male was admitted to the intensive coronary care unit of the Medical College Thiruvananthapuram in May 2001 with acute myocardial infarction. His electrocardiogram showed a large infarct involving the inferior and posterior left ventricle and right ventricle. He was brought to the intensive coronary care unit within 3 hours of the onset of chest pain. He was given thrombolytic therapy with intravenous streptokinase and was put on aspirin, metoprolol, captopril and lipid-lowering drugs. Coronary angiography was performed on him after 30 days in view of stress test positivity and class II angina. His right coronary artery was tortuous and full of thrombus in its mid and distal portions, with TIMI 0 flow distally. His left coronary artery was normal. He was taken for thrombectomy and coronary angioplasty. Vascular access was obtained through the right femoral artery using the standard Seldinger technique and a 7 French (Fr) arterial sheath was introduced. The right coronary artery (RCA) was cannulated with a 7 Fr JR 3.5 WISE Guide (Boston Scientific/Scimed, Inc., Maple Grove, Minnesota). A 0.014´´ Commander super support wire (USCI/Bard, Billerica, Massachusetts) was placed down the RCA and parked in the posterior descending artery. A 4.5 Fr Rescue Percutaneous Thrombectomy Catheter (Boston Scientific/Scimed, Inc.) was used to remove thrombus from the mid and distal RCA. With slow serial passage of the thrombectomy catheter connected to its suction apparatus, the RCA was cleared of the thrombus. Five brown-colored thrombi, each measuring 1–2 mm in size, were seen in the collection bottle. The distal RCA had 80% stenosis followed by a 90% stenosis in the precrux region. The proximal PDA had 70% stenosis. These lesions were dilated serially with a 1.5 x 20 mm Adante balloon (Boston Scientific/Scimed, Inc.) and a 3 x 20 mm Presto balloon (Occam, The Netherlands). TIMI 3 laminar flow was achieved. The patient was continued on an antiplatelet regimen of aspirin and clopidogrel. Following the procedure, there were no new electrocardiographic changes or significant elevations of cardiac enzymes. Discussion. Despite the use of lytics, aggressive antiplatelet agents, stents and thrombectomy devices, intracoronary thrombus remains a challenge for interventional catheter-based techniques. This is mainly due to insufficient reduction of thrombus and risk of distal embolization. Several devices have been developed to remove thrombus. The disadvantage of most of these devices is that their use is complicated. Moreover, they are not user-friendly. The Transluminal Extraction Catheter (Interventional Technologies, San Diego, California), which is basically an atherectomy device, is also useful for thrombectomy. Kaplan et al.1 reported a 94% angiographic success rate in acute myocardial infarction patients, but the device has a 6-month restenosis rate of 69%. The Angiojet2 (Possis Medical, Minneapolis, Minnesota) uses a high-velocity saline jet to create a venturi effect to dissolve the thrombus. The Rescue Percutaneous Thrombectomy system has been studied in the setting of acute myocardial infarction within 24 hours of onset of pain. Vincent van Ommen3 published a paper on his observations of 50 patients with 51 lesions (45 patients had thrombus in native coronary arteries and 5 had venous bypass graft thrombus) in which the thrombus could be removed from 48 of 51 vessels (94%). In 42 vessels (82%), additional balloon angioplasty was performed. TIMI 3 flow was obtained in 42 vessels (82%) after the suction of the thrombus, and was achieved in 47 vessels (92%) after additional balloon angioplasty. There were 2 deaths (1 patient had left main coronary artery stenosis and 1 had occluded venous bypass graft) a few hours after the procedure in spite of angiographically successful thrombectomy. The Rescue Percutaneous Thrombectomy system is a simple thrombectomy system using a catheter that can be handled like a balloon. The device is a 4.5 Fr monorail polyethylene catheter. There is a guidewire exit hole 30 cm from the distal tip. The catheter will fit into a 7 Fr or larger guiding catheter and is compatible with a 0.014´´ or smaller guidewire. There is a platinum marker band at the distal tip for visibility. The catheter is connected to a long tube via a luer fitting. A three-way stop cock is fixed to the luer lock to allow saline flush as necessary. The long tube is connected to a collection bottle that collects aspirated blood. A vacuum console is connected to the collection bottle. The vacuum generated in the collection bottle will suck blood and thrombus into the catheter. The catheter is advanced across the thrombus, using a “pecking” motion until the tip is distal to the thrombus. This system was found to be very effective, fast and safe in this case where the RCA was heavily loaded with thrombus and also had TIMI 0 flow distally. After aspirating the thrombus, the flow increased from TIMI 0 to TIMI 2. The distal severe lesions were well delineated, which helped the further strategy of angioplasty. Subsequent balloon angioplasty resulted in TIMI 3 flow with no significant residual stenosis. There was no distal embolization or slow flow phenomenon. No CK or CK-MB elevations or fresh ischemic electrocardiographic changes were noticed after the procedure. The Rescue Percutaneous Thrombectomy Catheter has been found to be useful for removing fresh thrombus from coronary arteries and bypass grafts in acute myocardial infarction. In the setting of acute myocardial infarction, the thrombus is soft and unorganized and can be aspirated. Our present case illustrates that the Rescue Percutaneous Thrombectomy Catheter can be used safely and effectively for removing thrombus even 1 month after acute myocardial infarction when the thrombus is more organized. Conclusion. Thrombus-containing coronary arteries are still a challenge to the interventional cardiologist despite the availability of glycoprotein IIb/IIIa antagonists and newer mechanical devices. The Rescue Percutaneous Thrombectomy Catheter effectively removed thrombus and facilitated the subsequent definitive treatment with balloon angioplasty one month after an acute myocardial infarction. This device was user-friendly and there were no complications.
1. Kaplam BM, Larkin T, Safian RD, et al. Prospective study of extraction atherectomy in patients with acute myocardial infarction. Am J Cardiol 1996;78:383‚Äì388. 2. Nagakawa Y, Matsuo S, Kimura T, et al. Thrombectomy with the Angiojet catheter in native coronary arteries for patients with acute or recent myocardial infarction. Am J Cardiol 1999;83:994‚Äì999. 3. van Ommen V, Michels R, Heymen E, et al. Usefulness of the Rescue PT catheter to remove fresh thrombus from coronary arteries and bypass grafts in acute myocardial infarction. Am J Cardiol 2001;88:306‚Äì308.