- Email: [email protected]
Instant dissolution of intracoronary thrombus by abciximab
International Journal of Cardiology 104 (2005) 102 – 103 www.elsevier.com/locate/ijcard
Letter to the Editor
Instant dissolution of intracoronary thrombus by abciximab Chi Hang LeeT, Kheng Thye Ho, Huay Cheem Tan Cardiac Department, Level 3, Main Building, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore Received 7 June 2004; accepted 14 August 2004 Available online 17 February 2005
Abstract Formation of intracoronary thrombus during percutaneous coronary intervention can lead to acute vessel closure and myocardial infarction if prompt action is not taken. Thrombus removal using mechanical thrombectomy is the common treatment approach. We report a rare case of thrombus formation immediately after guidewire advancement, causing acute myocardial ischemia. Intracoronary bolus of abciximab was given and this resulted in prompt dissolution of the thrombus. The procedure proceeded uneventfully and there was no myocardial damage. This is consistent with a recent report suggesting that intracoronary abciximab may be more beneficial than standard intravenous administration for patients undergoing emergency coronary intervention for acute coronary syndrome. D 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Intracoronary thrombus; Abciximab; Thrombectomy
1. Case report As a consequence of vascular injury and platelet aggregation, formation of intracoronary thrombus occasionally occurs after balloon dilatation and/or stent implantation during percutaneous coronary intervention (PCI); it can lead to catastrophic outcomes including myocardial infarction if immediate action is not taken to prevent the propagation of the coronary thrombus. We present an uncommon case of intracoronary thrombus formation immediately after guidewire advancement, resulting in acute myocardial ischemia; a single-bolus of intracoronary abciximab was administered and this resulted in prompt dissolution of the thrombus. Subsequent exercise myocardial perfusion scan did not reveal any perfusion defects. The patient was a 60-year-old man admitted for elective coronary intervention because of exertional angina. Diagnostic angiogram demonstrated a 90% focal stenosis in the proximal right coronary artery (RCA) (Fig. 1a), with normal antegrade flow (TIMI 3). The left anterior
T Corresponding author. Tel.: +65 67722493; fax: +65 68722998. E-mail address: [email protected] (C. Hang Lee). 0167-5273/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2004.08.076
descending artery and left circumflex artery were normal. The lesion looked clean without evidence of coronary thrombus. A six French Judkins Right (JR) 4 guiding catheter (Cordis, Johnson and Johnson, Warren, NJ) was engaged in the ostial RCA. Heparin 8000 U (100 U/kg) was given intra-arterially. A 0.01-in. Balance Middle Weight Universal guidewire (Guidant, Santa Clara, CA) crossed the lesion without difficulty. However, the patient complained of chest tightness and electrocardiographic monitoring showed 3-mm ST-segment elevation over leads II and III shortly after guidewire advancement, consistent with an evolving myocardial infarction. Angiography demonstrated a newly formed thrombus in the normal segment distal to the lesion (Fig. 1b), together with delayed antegrade flow (TIMI 2). A single-bolus of intracoronary abciximab (15 mg) was administered immediately. Coronary angiogram repeated 2 min after drug administration showed complete dissolution of the thrombus (Fig. 1c). Normal antegrade flow (TIMI 3) was restored. After thrombus dissolution, angiography confirmed the absence of dissection at the site of thrombus formation. The distal coronary branches were all patent, without evidence of distal embolization. The ST segment reverted to normal and anginal symptom improved
C. Hang Lee et al. / International Journal of Cardiology 104 (2005) 102–103
103
Fig. 1. (a) Baseline angiogram showing eccentric lesion in proximal right coronary artery. (b) Formation of intracoronary thrombus after advancement of guidewire. (c) Instant resolution of thrombus after intracoronary abciximab.
promptly. Activated clotting time was 416 s. The procedure was resumed and a coronary stent was implanted in the original lesion at 16 atm. Final angiogram showed 0% residual stenosis, TIMI 3 flow and no evidence of dissection. There was no elevation of creatinine kinase-MB after the procedure. The patient was discharged the next day. Exercise-stress, technetium-tetrofosman imaging was performed 2 weeks after the procedure. No perfusion defects were detected. The patient remained well and angina-free. Balloon angioplasty and/or stent implantation in order to crush the thrombus was the treatment approach before the availability of mechanical thrombectomy devices. [1] However, this often led to embolization of the microthrombi and distal vascular occlusion. Recently, mechanical thrombectomy using X-sizer or Possi Angiojet has been shown to be effective in removing intracoronary thrombus. [2–4] However, the device may not be available in all centers, takes time and expertise to operate. A recent report suggests that in patients with myocardial infarction undergoing emergency PCI, intracoronary abciximab may be more effective in reducing major adverse cardiac events than standard intravenous administration. [5] In this regard, our case report supports
the hypothesis that intracoronary abciximab facilitates the dissolution of coronary thrombus.
References [1] Timurkaynak T, Ozdemir M, Cengel A, Cemri M, Ciftci H, Yalcin R, et al. Direct stenting in angiographically apparent thrombus-containing lesions. J Invasive Cardiol 2001;13:742 – 7. [2] Kornowski R, Ayzenberg O, Halon DA, Kusniec F, Assali A. Preliminary experiences using X-sizer catheter for mechanical thrombectomy of thrombus-containing lesions during acute coronary syndromes. Catheter Cardiovasc Interv 2003;58:443 – 8. [3] Koneru S, Pucillo A, Weiss MB, Monsen C. Successful aspiration of occlusive coronary thrombus with intracoronary aspiration using the export catheter. J Invasive Cardiol 2003;15:65 – 7. [4] Beran G, Lang I, Schreiber W, Denk S, Stefenelli T, Syeda B, et al. Intracoronary thrombectomy with the X-sizer catheter system improves epicardial flow and accelerates ST-segment resolution in patients with acute coronary syndrome: a prospective, randomized, controlled study. Circulation 2002;105:2355 – 60. [5] Wohrle J, Grebe OC, Nusser T, Kamenz J, Nusser T, Grebe OC, et al. Reduction of major adverse cardiac events with intracoronary compared with intravenous bolus application of abciximab in patients with acute myocardial infarction or unstable angina undergoing coronary angioplasty. Circulation 2003;107:1840 – 3.
Letter to the Editor
Instant dissolution of intracoronary thrombus by abciximab Chi Hang LeeT, Kheng Thye Ho, Huay Cheem Tan Cardiac Department, Level 3, Main Building, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore Received 7 June 2004; accepted 14 August 2004 Available online 17 February 2005
Abstract Formation of intracoronary thrombus during percutaneous coronary intervention can lead to acute vessel closure and myocardial infarction if prompt action is not taken. Thrombus removal using mechanical thrombectomy is the common treatment approach. We report a rare case of thrombus formation immediately after guidewire advancement, causing acute myocardial ischemia. Intracoronary bolus of abciximab was given and this resulted in prompt dissolution of the thrombus. The procedure proceeded uneventfully and there was no myocardial damage. This is consistent with a recent report suggesting that intracoronary abciximab may be more beneficial than standard intravenous administration for patients undergoing emergency coronary intervention for acute coronary syndrome. D 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Intracoronary thrombus; Abciximab; Thrombectomy
1. Case report As a consequence of vascular injury and platelet aggregation, formation of intracoronary thrombus occasionally occurs after balloon dilatation and/or stent implantation during percutaneous coronary intervention (PCI); it can lead to catastrophic outcomes including myocardial infarction if immediate action is not taken to prevent the propagation of the coronary thrombus. We present an uncommon case of intracoronary thrombus formation immediately after guidewire advancement, resulting in acute myocardial ischemia; a single-bolus of intracoronary abciximab was administered and this resulted in prompt dissolution of the thrombus. Subsequent exercise myocardial perfusion scan did not reveal any perfusion defects. The patient was a 60-year-old man admitted for elective coronary intervention because of exertional angina. Diagnostic angiogram demonstrated a 90% focal stenosis in the proximal right coronary artery (RCA) (Fig. 1a), with normal antegrade flow (TIMI 3). The left anterior
T Corresponding author. Tel.: +65 67722493; fax: +65 68722998. E-mail address: [email protected] (C. Hang Lee). 0167-5273/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2004.08.076
descending artery and left circumflex artery were normal. The lesion looked clean without evidence of coronary thrombus. A six French Judkins Right (JR) 4 guiding catheter (Cordis, Johnson and Johnson, Warren, NJ) was engaged in the ostial RCA. Heparin 8000 U (100 U/kg) was given intra-arterially. A 0.01-in. Balance Middle Weight Universal guidewire (Guidant, Santa Clara, CA) crossed the lesion without difficulty. However, the patient complained of chest tightness and electrocardiographic monitoring showed 3-mm ST-segment elevation over leads II and III shortly after guidewire advancement, consistent with an evolving myocardial infarction. Angiography demonstrated a newly formed thrombus in the normal segment distal to the lesion (Fig. 1b), together with delayed antegrade flow (TIMI 2). A single-bolus of intracoronary abciximab (15 mg) was administered immediately. Coronary angiogram repeated 2 min after drug administration showed complete dissolution of the thrombus (Fig. 1c). Normal antegrade flow (TIMI 3) was restored. After thrombus dissolution, angiography confirmed the absence of dissection at the site of thrombus formation. The distal coronary branches were all patent, without evidence of distal embolization. The ST segment reverted to normal and anginal symptom improved
C. Hang Lee et al. / International Journal of Cardiology 104 (2005) 102–103
103
Fig. 1. (a) Baseline angiogram showing eccentric lesion in proximal right coronary artery. (b) Formation of intracoronary thrombus after advancement of guidewire. (c) Instant resolution of thrombus after intracoronary abciximab.
promptly. Activated clotting time was 416 s. The procedure was resumed and a coronary stent was implanted in the original lesion at 16 atm. Final angiogram showed 0% residual stenosis, TIMI 3 flow and no evidence of dissection. There was no elevation of creatinine kinase-MB after the procedure. The patient was discharged the next day. Exercise-stress, technetium-tetrofosman imaging was performed 2 weeks after the procedure. No perfusion defects were detected. The patient remained well and angina-free. Balloon angioplasty and/or stent implantation in order to crush the thrombus was the treatment approach before the availability of mechanical thrombectomy devices. [1] However, this often led to embolization of the microthrombi and distal vascular occlusion. Recently, mechanical thrombectomy using X-sizer or Possi Angiojet has been shown to be effective in removing intracoronary thrombus. [2–4] However, the device may not be available in all centers, takes time and expertise to operate. A recent report suggests that in patients with myocardial infarction undergoing emergency PCI, intracoronary abciximab may be more effective in reducing major adverse cardiac events than standard intravenous administration. [5] In this regard, our case report supports
the hypothesis that intracoronary abciximab facilitates the dissolution of coronary thrombus.
References [1] Timurkaynak T, Ozdemir M, Cengel A, Cemri M, Ciftci H, Yalcin R, et al. Direct stenting in angiographically apparent thrombus-containing lesions. J Invasive Cardiol 2001;13:742 – 7. [2] Kornowski R, Ayzenberg O, Halon DA, Kusniec F, Assali A. Preliminary experiences using X-sizer catheter for mechanical thrombectomy of thrombus-containing lesions during acute coronary syndromes. Catheter Cardiovasc Interv 2003;58:443 – 8. [3] Koneru S, Pucillo A, Weiss MB, Monsen C. Successful aspiration of occlusive coronary thrombus with intracoronary aspiration using the export catheter. J Invasive Cardiol 2003;15:65 – 7. [4] Beran G, Lang I, Schreiber W, Denk S, Stefenelli T, Syeda B, et al. Intracoronary thrombectomy with the X-sizer catheter system improves epicardial flow and accelerates ST-segment resolution in patients with acute coronary syndrome: a prospective, randomized, controlled study. Circulation 2002;105:2355 – 60. [5] Wohrle J, Grebe OC, Nusser T, Kamenz J, Nusser T, Grebe OC, et al. Reduction of major adverse cardiac events with intracoronary compared with intravenous bolus application of abciximab in patients with acute myocardial infarction or unstable angina undergoing coronary angioplasty. Circulation 2003;107:1840 – 3.