Broughton, Chad

Hu, Tom

Junaid, Farooq

Wildes, Daniel

English

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Tom Hu DO1, Daniel Wildes DO, FACC1, Farooq Junaid DO1, Chad Broughton RCIS1.1. Oklahoma State University Department of Cardiology, Tulsa, OKCase Presentation❖ HPI: A 53-year-old male presented to the ED with intermittent substernal chest pain for the previous two days. On admission, his pain became continuous, more intense and similar to the pain he had with a previous MI five years previous. His pain did not resolve with medical therapy so invasive evaluation was recommended.❖ PMH: CAD with previous MI (2014) treated with 2.5 x 28 DES LCx, Ischemic cardiomyopathy, HLD.❖ FHx: The patient was adopted. ❖ SHx: Daily tobacco use, ½ ppdfor 40 years, occasional alcohol use, no drug use.❖ Vitals on presentation: BP 134/79; HR 69; RR 18; Temp 36.7C; 99% on RA; BMI 20.9❖ Cardiovascular Exam:❖ Normal S1 and S2,❖ Regular rate and rhythm. ❖ No murmurs, rubs, or gallops appreciated.❖ Distal pulses are intact bilaterally.❖ Labs:❖ Troponin: 15❖ Potassium: 3.9, Creatinine 0.74Discussion❖ LMCA thrombosis is rare and carries a high mortality. Our case demonstrated an unusual cause of thrombus extending from a stented vessel into the LMCA. ❖ In the setting of AMI, we pursued several options that were described in the literature without immediate success. ❖ During runs with the aspiration catheter, we observed that the tip of the guide catheter was in close proximity to the mobile thrombus in the LCx and LMCA. This prompted an attempt at a novel technique of aspiration thrombectomy via the guide catheter that demonstrated immediate success. ❖ Our patient experienced no immediate or perioperative complications. ❖ Aspiration of thrombus through a  guide catheter may be an effective alternative technique in treating LMCA thrombus. Clinical CourseIntroduction❖ Left main coronary artery (LMCA) thrombosis during acute myocardial infraction is rare and carries high mortality. The etiology and clinical presentation are  variable. Our current understanding of LMCA thrombus largely comes from case reports. Etiology❖ Optimal evidence-based therapy for LMCA thrombosis is unclear based on current literature.Therapy Described by Previous LiteratureReference❖ Si, Daoyuan et al. “A new technique to salvage myocardium following the failure of thrombus aspiration in acute myocardial infarction: a case report.” BMC cardiovascular disorders vol. 18,1 228. 10 Dec. 2018, doi:10.1186/s12872-018-0951-9❖ Kapadia, Samir R., et al. “Successful Percutaneous Management of Left Main Trunk Occlusion during Percutaneous Aortic Valve Replacement.” Catheterization and Cardiovascular Interventions, vol. 73, no. 7, 2009, pp. 966–972., doi:10.1002/ccd.21867.❖ Patel, Nish, et al. “Stent-Based Mechanical Thrombectomy in Left Main Coronary Artery Thrombus Presenting as ST-Segment Elevation Myocardial Infarction.” JACC: Cardiovascular Interventions, vol. 10, no. 3, 2017, pp. 302–303., doi:10.1016/j.jcin.2016.10.038.AN UNUSUAL CASE OF LEFT MAIN CORONARY ARTERY THROMBUS TREATED WITH GUIDE CATHETER ASPIRATIONFigure 1. 12 lead EKG demonstrating lateral ST-depression with T waves inversion (A). Initial angiogram demonstrating 100% pLCx stenosis (B). Angiogram after stent deployment revealed trapped thrombus extending into LMCA. (C). Angiography after  multiple passes with the Pronto thrombectomy catheter demonstrating persistent thrombus (D&E). Angiography after aspiration through a CLS 3.5 guide catheter demonstrating successful removal of the thrombus (F&G). Intravascular ultrasound (IVUS) demonstrating the thrombus in the LMCA (H). Two fragments of aspirated thrombus. The largest measured 5 mm in diameter (I).AB CD EF GLAInitial presentation consistent with ACS/NSTEMIPatient was taken for left heart catheterization with Bivalirudin for PCIpLCx 100% stenosis in previous stent was treated with 2.5 x 28mm Xience Sierra DES deployed within the previous stent3.0 x 18mm Xience Sierra  deployed at the ostium of LCxfollowed by high-pressure post dilation Post PCI angiogram demonstrated a large, mobile thrombus trapped behind the proximal stent extending into LMCAEptifibatide was initiated. Multiple passes with an aspiration thrombectomy catheter and PTCA were unsuccessfulAspiration directly through a CLS 3.5 guide catheter extracted 2 large  fragments of thrombus. The largest  measured 5 mm in diameterThere appeared to be a nearly complete resolution of thrombus. The patient had repeat angiogram after Eptifibatide infusion revealed complete resolutionH IRAO 26.0CAU 27.2RAO 34.5CAU 27.2RAO 24.8CAU 20.9LAO 20.1CAU 33.6RAO 30.1CAU 20.0LAO 26.4CAU 29.0Acute Plaque RuptureEmbolization DissectionExtrinsic compressionUnstablePCISurgeryStableGlycoprotein II/III inhibitorHeparin

Unusual case of left main coronary artery thrombus treated with guide catheter aspiration

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Unusual case of left main coronary artery thrombus treated with guide catheter aspiration

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