A case of successful thrombectomy with coronary angioplasty balloon in a totally occluded right coronary artery/Total tikali sag koroner artere koroner anjiyoplasti balonuyla basarili trombektomi.

Introduction

The main goal in both the mechanical and thrombolytic approaches towards acute ST elevation myocardial infarction (STEMI) is to remove the thrombus from coronary arteries. High intracoronary thrombi materials often leads to failure effective percutaneous coronary intervention (PCI) results. Use of intracoronary devices is associated with a lower 30-day mortality in patients with STEMI (1). Thrombectomy with simple to use devices, is another attractive option for interventionalists (2). We present a case of successful embolectomy in the right coronary artery (RCA) using intracoronary Fogarty balloon technique.

Case Report

A 43 years old male patient was admitted to our clinic for chest pain. After establishing the diagnosis of acute inferior STEMI, he was given streptokinase 1.5 millionU/h. His arterial blood pressure was 110/70 mm Hg and pulse--76/min.Coronary angiography was performed due to recurring chest pain within 24 hours after thrombolytic therapy. In coronary angiography, total occlusion of the RCA at the proximal site by the thrombus (Fig. 1) and retrograde filling at the left distal to the RCA were observed. The lesion was passed by the help of intermediate guide wire and balloon support. Excessive thrombus burden was observed. Despite repeated dilations of lesions by the balloon, there were no any change in the thrombus burden (Fig. 2). Thrombus extended from proximal of the RCA up to distal RCA. Then, balloon was inflated at 3-4 atmospheric pressure while it was in distal RCA, and was withdrawn towards proximal RCA into the guiding catheter while it was slightly inflated (Fig. 3). After balloon was withdrawn into the guiding catheter, it was inflated more at 1-2 atm. When it was ensured that the balloon contained the entire guiding catheter, whole system (guiding catheter, balloon and guide wire) was removed from femoral artery. Fresh thrombotic material in one piece (3-4 cm) was observed inside the guiding catheter. A new guiding catheter was inserted in RCA ostium and it was seen that almost all thrombi within the artery were cleared (Fig. 4). Then, stent was inserted inside medium and proximal stenosis and TIMI-3 flow was established (Fig. 5). During and after the procedure no complication occurred and the procedure was completed. No complications occurred in the patient followed in coronary intensive unit and at 1-month control.

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Discussion

Excessive thrombus burden in coronary arteries is among the important factors affecting the success of intervention and its association with poor prognosis is well known (3). Thus, currently several thrombectomy devices are used in order to remove thrombus burden of thrombotic lesions in STEMI, when thrombolytic therapy and percutaneous coronary intervention fail to provide adequate improvement (4, 5). Although it is rare, thrombectomy procedure with special filters and protective devices has been reported to be successful with Fogarty maneuver (6). We considered angioplasty balloon as Fogarty catheter in order to remove the thrombus from the arteries in our patient presenting with STEMI and scheduled for PCI due to unavailability of accessory devices. We chose balloon thrombectomy procedure mainly because the patient was young with large ischemic area and his chest pain persisted. Low tortuousness of the RCA and large artery diameter allowed easy performance of the procedure. On the other hand, some complications may occur during use of other thrombectomy methods. These methods have their own limitations and advantages (7). Major complications of mechanical thrombectomy devices include distal embolization, dissection, perforation and no-reflow phenomenon (8). The absence of no-reflow phenomenon and dissection in our patient despite no use of distal protection device may be explained by the marked decrease in the present coronary thrombus burden with use of effective thrombectomy. After first balloon inflation, there was spiral like dissection throughout RCA, but no dissection was further seen in serial angiographic views. Case of coronary perforation has been reported following use of thrombectomy devices (9). We believe that younger age of the patient and well-developed RCA decreased his risk for perforation. It was found that stent insertion after thrombectomy for thrombotic lesions in STEMI had more favorable effects on left ventricular function compared to direct stent insertion. However, cover stent was used in order to affix thrombus to artery wall in thrombotic lesion but this is not recommended due to very high rates of restenosis (10).

Conclusion

We report a case of successful balloon thrombectomy procedure in a patient with STEMI. Application and safety of this procedure need to be tested in the large clinical study.

The case was presented at the XXIII. National Congress of Cardiology, 19-23 November, 2007, Antalya, Turkey

References

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(5.) De Rosa S, Cirillo P, De Luca G, Galasso G, Esposito G, Leosco D et al. Rheolytic thrombectomy during percutaneous coronary intervention improves long-term outcome in high-risk patients with acute myocardial infarction. J Interv Cardiol 2007; 20: 292-8.

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(7.) Constantinides S, Lo TS, Been M, Shiu MF, Tizun J, Fernandez Sanchez-Villaran E et al. Guide-wire rupture as a complication of coronary angioplasty. Early experience with a helical coronary thrombectomy device in patients with acute coronary thrombosis. Heart 2002; 87: 455-60.

(8.) Kotani JI, Nanto S, Mintz GS, Kitakaze M, Ohara T, Morozumi T et al. Plaque gruel of atheromatous coronary lesion may contribute to the no-reflow in patients with acute coronary syndrome. Circulation 2002; 106: 1672-7.

(9.) Constantinidis S, Lo TSN, Been M, Shiu MF. Early experience with a helical coronary thrombectomy device in patients with acute coronary thrombosis. Heart 2002, 87: 455-60.

(10.) Greckens U, Muller R, Cattelaens N, Herchenbach, Grube E. The new coronary stent graft JoStent first clinical experience. J Am Coll Cardiol 1998,31 (Suppl): 414A. (abstract)

Ibrahim Halil Kurt

Department of Cardiology, Adana Numune Education and Research Hospital, Adana, Turkey

Address for Correspondence/Yazisma Adresi: Dr. Ibrahim Halil Kurt, Department of Cardiology, Adana Numune Education and Research Hospital, Adana, Turkey Phone: [phone] Fax: [phone] E-mail: [e-mail]