Primary percutaneous intervention (PCI) in acute ST elevation myocardial infarction (MI) is a preferred way of treatment nowadays. Sometimes it becomes difficult to get good myocardial blood flow during PCI if clot burden is large. In this case of an elderly lady, the use of  Mother and Child Technique  combined with super selective pharmacological intervention is demonstrated to achieve good blood flow when conventional means are not working

Dhakam, Sajid H.

Rahman, Nasir

eCommons@AKU

eCommons@AKUSection of Cardiology Department of MedicineOctober 2011Mother and child technique combined with superselective pharmacological intervention for largeintracoronary thrombusNasir RahmanAga Khan UniversitySajid H. DhakamAga Khan UniversityFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_med_cardiolPart of the Cardiology CommonsRecommended CitationRahman, N., Dhakam, S. (2011). Mother and child technique combined with super selective pharmacological intervention for largeintracoronary thrombus. Journal of the College of Physicians and Surgeons Pakistan, 21(10), 644-6.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_med_cardiol/3644 Journal of the College of Physicians and Surgeons Pakistan  2011, Vol. 21 (10): 644-646INTRODUCTIONAcute ST-elevation myocardial infarction (MI) has alwaysbeen a catastrophic event. Primary percutaneous inter-vention (PCI) has shown to decrease the mortality inpatients with acute MI. Primary PCI in patients with alarge thrombus burden is a demanding clinical situationassociated with impaired clinical outcomes.1 Mechanicaland pharmacological management of coronary throm-bosis has been shown to effectively remove a variablefraction of intracoronary thrombus. Pharmacologicaltherapies as well as different mechanical therapies havebeen used to remove clot from coronary arteries.In rare circumstances, the clot burden may be so largethat this becomes very difficult to extract clot and restoreflow despite available means (aspiration catheters).Here, the authors have demonstrated a new techniquewith a self-made “Mother and Child catheter” with largerinternal luminal diameter (ILD) along with superselective pharmacological management to retrieve clot.Procedure: This is the case summary of a 65 years oldwoman without any risk factors for coronary arterydisease. She presented with 3 days history of inter-mittent shortness of breath and chest discomfort.Because of cardiogenic pulmonary edema, she requiredartificial ventilation. On admission, her EKG revealed3-4 mm ST segment elevation in precordial leads. Shewas brought to cardiac catheterization laboratory withdiagnosis of acute anterior wall myocardial infarction forpossible primary PCI. Patient was pre-treated withAspirin 300 mg, Clopidogrel 600 mg and bolus ofunfractionated intravenous Heparin. Her coronaryangiogram performed through right femoral arteryrevealed totally occluded mid left anterior descendingartery (LAD) just after S1 with large clot burden and non-obstructive disease in the rest of the vessels (Figure 1).It was decided to proceed with primary PCI of mid LAD.Left main was engaged with judkins left (JL) 3.5 6F(cordis), internal diameter (I.D.) 0.070 inches (1.8 mm)100 cm long catheter. LAD was wired with Cougar XT(HT) 0.014 x 190 cm (Medtronic) wire. Aspiration donewith 6F export aspiration (Medtronic) I.D, 0.054 inches(1.37 mm) catheter. Despite repeated attempts the flowcould not be restored and each time export aspirationcatheter tends to clog off. Activated clotting time waskept more than 250 second. Balloon dilatation done withNimbus Pico (clear stream) 2.5 x 15 mm at 2-4 atm. inmid LAD but still unable to restore flow. Mother andChild Technique with 6F and 8F catheters was used toretrieve thrombus. A 100 cm JL 3.5 8F (cordis), I.D, 0.88inches (2.2 mm). Guiding catheter was cut fromproximal end at about 20 cm and mouth of the proximalend was opened using the dilator of 8F femoral sheath.This catheter was used as “mother catheter”. A 100 cmmultipurpose A1 (MPA1) 6F (cordis), I.D, 0.070 inches(1.8 mm) was used as “child catheter”. This wasintroduced through proximal end of 8F JL3.5 8F catheter(Figure 2). The 6F MPA1 tip was kept inside the tip of 8FJL3.5 catheter and left main vessel was engaged withJL3.5 8F catheter. LAD was wired again with Cougar XT(HT) 0.014 x 190 cm (Medtronic) wire. Over the wire 6FMPA1 catheter advanced into the LAD and passed up tothe mid LAD (Figure 3). Aspiration was done with thehelp of a 20 cc syringe through MPA1 6F catheter. Afterthree aspirations and taking out large thrombus, the flowwas restored in the left anterior descending artery.Keeping in view the large thrombus and also someresidual thrombus in distal LAD, super selectivepharmacological therapy with Abciximab bolus and halfdose (125 KU) of intracoronary streptokinase was given.ABSTRACTPrimary percutaneous intervention (PCI) in acute ST elevation myocardial infarction (MI) is a preferred way of treatmentnowadays. Sometimes it becomes difficult to get good myocardial blood flow during PCI if clot burden is large. In this caseof an elderly lady, the use of “Mother and Child Technique” combined with super selective pharmacological intervention isdemonstrated to achieve good blood flow when conventional means are not working.Key words: Mother and child technique.  Primary percutaneous intervention.  Intracoronary thrombus.Department of Cardiology1 / Medicine2, The Aga Khan UniversityHospital, Karachi.Correspondence: Dr. Nasir Rahman, Consultant InterventionalCardiologist, The Aga Khan University Hospital, Stadium Road,Karachi.E-mail: nasir.rahman@aku.eduReceived  January 08, 2011;  accepted September 07, 2011.“Mother and Child Technique” Combined with Super SelectivePharmacological Intervention for Large Intracoronary Thrombus Nasir Rahman1 and Sajid Dhakam2TECHNIQUEAfter restoring flow, it was decided to defer any stentingand have a re-look angiogram after 72 hours. Patientwas kept on anti-platelet agents. Relook coronaryangiogram after 72 hours showed patent LAD with TIMI111 flow with myocardial blush grade of 2-3 and non-obstructive disease in mid LAD (Figure 4). It wasdecided not to stent the vessel and continue anti-platelettherapy. She was extubated after 4 days of her indexadmission and her subsequent hospital course wasuneventful from cardiac point. After 2 months of followup, patient is asymptomatic and doing well.DISCUSSIONAcute MI with ST-segment elevation is caused by therupture or erosion of an atherosclerotic plaque, whichleads to intraluminal thrombosis and hence resulting incomplete occlusion of a coronary artery.1 Primary PCI isnow the preferred treatment for myocardial infarctionwith ST-segment elevation and is effective in openingthe infarct-related artery with better outcome.2 One ofthe problems which an interventional cardiologist canencounter during PCI is large clot burden and no-reflow.Sometimes, this becomes impossible to achieve goodmyocardial blush grade because of large clot burdenand no-re-flow. This has been shown that use of a 6Fcompatible aspiration catheter for thrombus aspirationresulted in better myocardial blush grade and ST-segment elevation resolution and hence resulted inbetter reperfusion and clinical outcomes than conven-tional PCI, irrespective of clinical and angiographiccharacteristics at baseline.3In this case we tried such an aspiration catheter multipletimes but flow restoration and clot extraction could notbe achieved despite repeated attempts. Due to the highfrequency of suboptimal myocardial reperfusion afterprimary PCI in some cases many devices to extract clotand protect microcirculation have been used but withconflicting results.4,5 Moreover, these devices are alsonot readily available in many catheterization laboratories.This was one of the cases in which conventional meansof extracting clot were unsuccessful and there was aJournal of the College of Physicians and Surgeons Pakistan  2011, Vol. 21 (10): 644-646  645“Mother and child technique” combined with super selective pharmacological intervention for large intracoronary thrombusFigure 1: Mid LAD with large clot burden.Figure 4: Patent LAD with non-obstructive disease in mid LAD 72 hours later.Figure 2: Panel A, JL 3.5 8F (cordis) guiding catheter “Mother Catheter” cutat proximal end at about 20 cm, Panel B, Mouth of the proximal end of JL3.5catheter was opened using the dilator of 8F femoral sheath, Panel C&D, A100 cm multipurpose A1 6F (Cordis) “Child catheter” introduced throughproximal end of 8F JL3.5 8F catheter.Figure 3: MPA1 catheter advanced into the LAD and passed up to the midLAD.need to have larger caliber catheter to extract clot. Theoriginal idea of “Mother and Child Technique” wasproposed by Takahashi et al. with the use of a 5F and 6Fcatheter (as mother and child catheters) to have bettersupport and cross lesion especially in patients withchronic total occlusion.6 In this case, more internalluminal diameter was required to get maximum clotretrieval. Therefore, 6F MPA1 catheter was used aschild catheter and JL3.5 8F catheter as mother catheterto get larger ILD and maximum backup support toextract clot. Though there can be a concern regardingvessel injury with the use of such catheter due to itsstiffness, we believe this can be easily used when anyother maneuver is not working, and to be on safe side,one can use the shaft of balloon catheter to pass childcatheter inside the vessel. This technique was found tobe extremely helpful to remove clot when conventionalmeans were not working. After the removal of most ofthe clot, super selective pharmacological treatment canget rid of some residual distal LAD clot to prevent clotformation again as suggested by Cortese et al.7To our knowledge, this is the first case where theuse of self-made “Mother and Child Catheter” wasdemonstrated with larger bore catheters and combinedwith the use of super selective pharmacologicalmanagement to achieve flow and good myocardialblush grade.REFERENCES1. Falk E. Plaque rupture with severe pre-existing stenosisprecipitating coronary thrombosis: characteristics of coronaryatherosclerotic plaques underlying fatal occlusive thrombi.Br Heart J 1983; 50:127-34.2. Keeley EC, Boura JA, Grines CL. Primary angioplasty versusintravenous thrombolytic therapy for acute myocardial infarction:a quantitative review of 23 randomised trials. Lancet 2003; 361:13-20.3. Svilaas T, Vlaar PJ, van der Horst IC, Diercks GF, de Smet BJ,van den Heuvel AF, et al. Thrombus aspiration during primarypercutaneous coronary intervention. N Engl J Med 2008; 358: 557-67.4. Ali A, Cox D, Dib N, Brodie B, Berman D, Gupta N, et al.Rheolytic thrombectomy with percutaneous coronary inter-vention for infarct size reduction in acute myocardial infarction:30-day results from a multicenter randomized study.  J Am CollCardiol 2006; 48:244-52. Epub 2006 Jun 23.5. Lefèvre T, Garcia E, Reimers B, Lang I, di Mario C, Colombo A,et al. X-sizer for thrombectomy in acute myocardial infarctionimproves ST-segment resolution: results of the X-sizer in AMIfor negligible embolization and optimal resolution (X AMINE ST)trail. J Am Coll Cardiol 2005; 46:246-52. 6. Takahashi S, Saito S, Tanaka S, Miyashita Y, Shiono T, Arai F,et al. New method to increase a backup support of a 6 Frenchguiding coronary catheter. Cathter and Cardiovasc Interven 2004;63:452-6.7. Cortese B, Micheli A, Picchi A, Limbruno U. Combined,superselective pharmacological management of large coronarythrombus burden.  J Invasive Cardiol 2009; 21:168-71.646 Journal of the College of Physicians and Surgeons Pakistan  2011, Vol. 21 (10): 644-646Nasir Rahman and Sajid Dhakaml l l l lOl l l l l

Mother and child technique combined with super selective pharmacological intervention for large intracoronary thrombus

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Mother and child technique combined with super selective pharmacological intervention for large intracoronary thrombus

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