- Email: [email protected]
A patient with an extensive coronary artery thrombus
Accepted Manuscript A Patient with an Extensive Coronary Artery Thrombus George Chalikias, MD, PhD, Petros Kikas, MD, Adina Thomaidis, MD, Levent Serif, MD, Georgios Georgiadis, MD, PhD, Dimitrios Tziakas, MD, PhD, FESC, FAHA, FACC, FSCAI PII:
S1109-9666(17)30471-2
DOI:
10.1016/j.hjc.2017.11.002
Reference:
HJC 220
To appear in:
Hellenic Journal of Cardiology
Received Date: 20 September 2017 Revised Date:
29 October 2017
Accepted Date: 1 November 2017
Please cite this article as: Chalikias G, Kikas P, Thomaidis A, Serif L, Georgiadis G, Tziakas D, A Patient with an Extensive Coronary Artery Thrombus, Hellenic Journal of Cardiology (2017), doi: 10.1016/ j.hjc.2017.11.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT A Patient with an Extensive Coronary Artery Thrombus Short Title : Intracoronary Thrombi
RI PT
George Chalikias 1MD, PhD, Petros Kikas 1MD, Adina Thomaidis 1MD, Levent Serif 1MD,
SC
Georgios Georgiadis 2 MD,PhD, Dimitrios Tziakas 1MD, PhD, FESC, FAHA, FACC, FSCAI
Cardiology1 and Vascular Surgery2 Department, Medical School, Democritus
Address for Correspondence
TE D
Dimitrios Tziakas
M AN U
University of Thrace, Alexandroupolis, Greece
Cardiology Department, Medical School, Democritus University of Thrace
EP
University Hospital of Alexandroupolis, Dragana, Alexandroupolis, Greece
AC C
Tel +30 2551353205
Mob +30 6974410539
Fax +30 2551353245
e-mail [email protected] Word Count : 940
Figures: 1 (3 parts)
Keywords: coronary thrombosis; acute coronary syndrome; percutaneous coronary intervention
ACCEPTED MANUSCRIPT In patients presenting with acute coronary syndromes (ACS) either ST elevation myocardial infarction or non ST elevation myocardial infarction (NSTEMI) / unstable angina, an early invasive strategy has been shown to reduce cardiovascular adverse events and to improve prognosis in this clinical setting. [1,2] As a result of this
RI PT
strategy of early intervention, the interventional cardiologist is faced upon a high prevalence of thrombotic burden. [3] The management of such lesions especially in the absence of an underlying stenotic or dissecting lesion is associated with high
SC
incidence of periprocedural complications. [4]
M AN U
A 47 year-old man presented with a non-ST elevation myocardial infarction. The patient reported continuous chest pain at rest, with typical angina characteristics associated with diaphoresis and nausea for 4 hours since admission. His electrocardiogram (ECG) showed ST segment depression in leads I, aVL, V4, V5 and V6. His medical history was unremarkable apart from an episode of deep vein
TE D
thrombosis of the right leg 15 years ago. Except from being a current smoker no other cardiovascular risk factors were present. Symptoms and ECG ischemic changes
EP
subsided with appropriate medical therapy (aspirin, ticagrelor, low molecular weight heparin, beta blocker, and IV nitrate).
AC C
Coronary angiography on admission day revealed an extensive thrombus at the mid portion of the right coronary artery (RCA) with no apparent significant stenotic or dissecting lesions (Fig. 1A). However, a non-critical stenotic (<50%) atherosclerotic lesion may be apparent at the initial 2 cm of the artery, although a localized vessel spasm due to
deep positioning of the catheter within RCA ostium cannot be
excluded. Left anterior descending and circumflex arteries were without significant stenotic lesions.
For the next 48 hours a glycoprotein IIb/IIIa platelet receptor
antagonist was continuously infused (tirofiban was used at a bolus dose of
25
ACCEPTED MANUSCRIPT microgram/kg given over a 3 minute period, followed by a continuous infusion at a rate of 0.15 microgram/kg/min for 48 hours). Despite this regimen of quadruple antithrombotic therapy (aspirin, ticagrelor, a low molecular weight heparin and tirofiban), thrombus was only partially resolved in a repeat coronary angiography,
RI PT
performed on the fifth hospitalization day (Fig. 1B). Following the second diagnostic angiography direct drug eluding stent (3.5mmx22mm) placement was performed (Fig. 1C).
SC
Discussion
M AN U
Although percutaneous coronary intervention technology and adjunctive pharmacotherapy have greatly advanced during recent years, these lesions (extensive thrombi with no apparent significant stenotic or dissecting pathology) remain a challenge since they are associated with a substantial risk of peri- and post-procedural
TE D
complications. Peri-procedural myocardial infarction, distal embolization and long term cardiac adverse events may occur. [4] Several treatment methods have been applied for the management extensive coronary thrombus. Balloon angioplasty and
EP
stent placement, intravenous antithrombotic therapy, intracoronary thrombolytic treatment, intracoronary pharmacotherapy (adenosine, calcium channel blockers,
AC C
abciximab, sodium nitroprusside), thrombectomy or thrombus aspiration devices and distal embolic protection devices have been used with ambiguous results. [4,5] Furthermore, a more thorough diagnostic approach is warranted in the majority of these mainly thrombotic lesions in order to reveal possible underlying causes such as concealed vessel dissection, inflammatory conditions or vessel vasculitis. [6,7] With the exception of the recommendation IIb of aspiration thrombectomy for selective and bailout cases in the recent focused update (2015) of the
ACCEPTED MANUSCRIPT ACC/AHA/SCAI Practical Guidelines regarding primary percutaneous coronary intervention there is no evidence-based algorithm for the treatment of these thrombotic lesions. [8] Similar IIb recommendation for aspiration thrombectomy has been also adapted for selected cases by the European Society of Cardiology. [9] This
RI PT
case underscores the need of developing more elaborate and evidence based treatment
SC
algorithms for the management of extensive coronary artery thrombi.
Funding source : none
References
M AN U
Conflict of interest: none
TE D
[1] O’Gara PT, Kushner FG, Ascheim DD, , Casey DE Jr, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-
EP
Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2013 ACCF/AHA
AC C
guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;61:e78–140. [2] Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, Holmes DR Jr, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014 ACC/AHA guideline for the management of patients with non–ST-elevation acute coronary syndromes: a
ACCEPTED MANUSCRIPT report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;64:e139-228. [3] DeWood MA, Spores J, Notske R, Mouser LT, Burroughs R, Golden MS, Lang
myocardial infarction. N Engl J Med 1980;303:897-902.
RI PT
HT. Prevalence of total coronary occlusion during the early hours of transmural
[4] Matar F, Mroue J. The management of thrombotic lesions in the cardiac
SC
catheterization laboratory. J of Cardiovasc Trans Res 2012;5:52-61.
[5] Hassink RJ, Haerkens-Arends HE, Daniels MC. Extensive right coronary artery
M AN U
thrombosis. Neth Heart J 2009;17:115-116.
[6]. Michas G, Stougiannos P, Thomopoulos T, Grigoriou K, Blazakis G, Kaplanis I, Gavrielatos G, Trikas A. Acute anterior myocardial infarction due to stent thrombosis after mushroom consumption: A case of Kounis type III syndrome. Hellenic J
TE D
Cardiol. 2017 Jan 6. pii: S1109-9666(16)30342-6. doi: 10.1016/j.hjc.2016.12.007. [7]. Li X, Lei Y, Zheng Q. Myocardial infarction caused by coronary artery dissection
EP
due to blunt injury: is thromboaspiration an appropriate treatment? Hellenic J Cardiol.
AC C
2014;55:61-64.
[8] Levine GN, O’Gara PT, Bates ER, Blankenship JC, Kushner FG, Bailey SR, Bittl JA, Brindis RG, Casey DE Jr, Cercek B, Chambers CE, Chung MK, de Lemos JA, Diercks DB, Ellis SG, Fang JC, Franklin BA, Granger CB, Guyton RA, Hollenberg SM, Khot UN, Krumholz HM, Lange RA, Linderbaum JA, Mauri L, Mehran R, Morrow DA, Moussa ID, Mukherjee D, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Ting HH, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for
ACCEPTED MANUSCRIPT patients with ST-elevation myocardial Infarction: An update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology/American Heart Association Task
RI PT
Force on Clinical Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv 2016;87:1001-1019.
[9] Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, Filippatos G,
SC
Hamm C, Head SJ, Jüni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer
M AN U
G, Neumann FJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A. ESC/EACTS Guidelines on
AC C
EP
TE D
myocardial revascularization. Eur Heart J 2014;35:2541–2619.
ACCEPTED MANUSCRIPT Figure Legend Figure 1 A. Right coronary artery left anterior oblique projection (45o), with extensive thrombus in the mid-portion; B. Same coronary artery as (A), left anterior
RI PT
oblique projection (45o) at repeat coronary angiography after 5 days of quadruple antithrombotic therapy; C. same coronary artery as (A) post coronary stenting, left
AC C
EP
TE D
M AN U
SC
anterior oblique projection (30o)
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S1109-9666(17)30471-2
DOI:
10.1016/j.hjc.2017.11.002
Reference:
HJC 220
To appear in:
Hellenic Journal of Cardiology
Received Date: 20 September 2017 Revised Date:
29 October 2017
Accepted Date: 1 November 2017
Please cite this article as: Chalikias G, Kikas P, Thomaidis A, Serif L, Georgiadis G, Tziakas D, A Patient with an Extensive Coronary Artery Thrombus, Hellenic Journal of Cardiology (2017), doi: 10.1016/ j.hjc.2017.11.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT A Patient with an Extensive Coronary Artery Thrombus Short Title : Intracoronary Thrombi
RI PT
George Chalikias 1MD, PhD, Petros Kikas 1MD, Adina Thomaidis 1MD, Levent Serif 1MD,
SC
Georgios Georgiadis 2 MD,PhD, Dimitrios Tziakas 1MD, PhD, FESC, FAHA, FACC, FSCAI
Cardiology1 and Vascular Surgery2 Department, Medical School, Democritus
Address for Correspondence
TE D
Dimitrios Tziakas
M AN U
University of Thrace, Alexandroupolis, Greece
Cardiology Department, Medical School, Democritus University of Thrace
EP
University Hospital of Alexandroupolis, Dragana, Alexandroupolis, Greece
AC C
Tel +30 2551353205
Mob +30 6974410539
Fax +30 2551353245
e-mail [email protected] Word Count : 940
Figures: 1 (3 parts)
Keywords: coronary thrombosis; acute coronary syndrome; percutaneous coronary intervention
ACCEPTED MANUSCRIPT In patients presenting with acute coronary syndromes (ACS) either ST elevation myocardial infarction or non ST elevation myocardial infarction (NSTEMI) / unstable angina, an early invasive strategy has been shown to reduce cardiovascular adverse events and to improve prognosis in this clinical setting. [1,2] As a result of this
RI PT
strategy of early intervention, the interventional cardiologist is faced upon a high prevalence of thrombotic burden. [3] The management of such lesions especially in the absence of an underlying stenotic or dissecting lesion is associated with high
SC
incidence of periprocedural complications. [4]
M AN U
A 47 year-old man presented with a non-ST elevation myocardial infarction. The patient reported continuous chest pain at rest, with typical angina characteristics associated with diaphoresis and nausea for 4 hours since admission. His electrocardiogram (ECG) showed ST segment depression in leads I, aVL, V4, V5 and V6. His medical history was unremarkable apart from an episode of deep vein
TE D
thrombosis of the right leg 15 years ago. Except from being a current smoker no other cardiovascular risk factors were present. Symptoms and ECG ischemic changes
EP
subsided with appropriate medical therapy (aspirin, ticagrelor, low molecular weight heparin, beta blocker, and IV nitrate).
AC C
Coronary angiography on admission day revealed an extensive thrombus at the mid portion of the right coronary artery (RCA) with no apparent significant stenotic or dissecting lesions (Fig. 1A). However, a non-critical stenotic (<50%) atherosclerotic lesion may be apparent at the initial 2 cm of the artery, although a localized vessel spasm due to
deep positioning of the catheter within RCA ostium cannot be
excluded. Left anterior descending and circumflex arteries were without significant stenotic lesions.
For the next 48 hours a glycoprotein IIb/IIIa platelet receptor
antagonist was continuously infused (tirofiban was used at a bolus dose of
25
ACCEPTED MANUSCRIPT microgram/kg given over a 3 minute period, followed by a continuous infusion at a rate of 0.15 microgram/kg/min for 48 hours). Despite this regimen of quadruple antithrombotic therapy (aspirin, ticagrelor, a low molecular weight heparin and tirofiban), thrombus was only partially resolved in a repeat coronary angiography,
RI PT
performed on the fifth hospitalization day (Fig. 1B). Following the second diagnostic angiography direct drug eluding stent (3.5mmx22mm) placement was performed (Fig. 1C).
SC
Discussion
M AN U
Although percutaneous coronary intervention technology and adjunctive pharmacotherapy have greatly advanced during recent years, these lesions (extensive thrombi with no apparent significant stenotic or dissecting pathology) remain a challenge since they are associated with a substantial risk of peri- and post-procedural
TE D
complications. Peri-procedural myocardial infarction, distal embolization and long term cardiac adverse events may occur. [4] Several treatment methods have been applied for the management extensive coronary thrombus. Balloon angioplasty and
EP
stent placement, intravenous antithrombotic therapy, intracoronary thrombolytic treatment, intracoronary pharmacotherapy (adenosine, calcium channel blockers,
AC C
abciximab, sodium nitroprusside), thrombectomy or thrombus aspiration devices and distal embolic protection devices have been used with ambiguous results. [4,5] Furthermore, a more thorough diagnostic approach is warranted in the majority of these mainly thrombotic lesions in order to reveal possible underlying causes such as concealed vessel dissection, inflammatory conditions or vessel vasculitis. [6,7] With the exception of the recommendation IIb of aspiration thrombectomy for selective and bailout cases in the recent focused update (2015) of the
ACCEPTED MANUSCRIPT ACC/AHA/SCAI Practical Guidelines regarding primary percutaneous coronary intervention there is no evidence-based algorithm for the treatment of these thrombotic lesions. [8] Similar IIb recommendation for aspiration thrombectomy has been also adapted for selected cases by the European Society of Cardiology. [9] This
RI PT
case underscores the need of developing more elaborate and evidence based treatment
SC
algorithms for the management of extensive coronary artery thrombi.
Funding source : none
References
M AN U
Conflict of interest: none
TE D
[1] O’Gara PT, Kushner FG, Ascheim DD, , Casey DE Jr, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-
EP
Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2013 ACCF/AHA
AC C
guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;61:e78–140. [2] Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, Holmes DR Jr, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014 ACC/AHA guideline for the management of patients with non–ST-elevation acute coronary syndromes: a
ACCEPTED MANUSCRIPT report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014;64:e139-228. [3] DeWood MA, Spores J, Notske R, Mouser LT, Burroughs R, Golden MS, Lang
myocardial infarction. N Engl J Med 1980;303:897-902.
RI PT
HT. Prevalence of total coronary occlusion during the early hours of transmural
[4] Matar F, Mroue J. The management of thrombotic lesions in the cardiac
SC
catheterization laboratory. J of Cardiovasc Trans Res 2012;5:52-61.
[5] Hassink RJ, Haerkens-Arends HE, Daniels MC. Extensive right coronary artery
M AN U
thrombosis. Neth Heart J 2009;17:115-116.
[6]. Michas G, Stougiannos P, Thomopoulos T, Grigoriou K, Blazakis G, Kaplanis I, Gavrielatos G, Trikas A. Acute anterior myocardial infarction due to stent thrombosis after mushroom consumption: A case of Kounis type III syndrome. Hellenic J
TE D
Cardiol. 2017 Jan 6. pii: S1109-9666(16)30342-6. doi: 10.1016/j.hjc.2016.12.007. [7]. Li X, Lei Y, Zheng Q. Myocardial infarction caused by coronary artery dissection
EP
due to blunt injury: is thromboaspiration an appropriate treatment? Hellenic J Cardiol.
AC C
2014;55:61-64.
[8] Levine GN, O’Gara PT, Bates ER, Blankenship JC, Kushner FG, Bailey SR, Bittl JA, Brindis RG, Casey DE Jr, Cercek B, Chambers CE, Chung MK, de Lemos JA, Diercks DB, Ellis SG, Fang JC, Franklin BA, Granger CB, Guyton RA, Hollenberg SM, Khot UN, Krumholz HM, Lange RA, Linderbaum JA, Mauri L, Mehran R, Morrow DA, Moussa ID, Mukherjee D, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Ting HH, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for
ACCEPTED MANUSCRIPT patients with ST-elevation myocardial Infarction: An update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology/American Heart Association Task
RI PT
Force on Clinical Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv 2016;87:1001-1019.
[9] Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, Filippatos G,
SC
Hamm C, Head SJ, Jüni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer
M AN U
G, Neumann FJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A. ESC/EACTS Guidelines on
AC C
EP
TE D
myocardial revascularization. Eur Heart J 2014;35:2541–2619.
ACCEPTED MANUSCRIPT Figure Legend Figure 1 A. Right coronary artery left anterior oblique projection (45o), with extensive thrombus in the mid-portion; B. Same coronary artery as (A), left anterior
RI PT
oblique projection (45o) at repeat coronary angiography after 5 days of quadruple antithrombotic therapy; C. same coronary artery as (A) post coronary stenting, left
AC C
EP
TE D
M AN U
SC
anterior oblique projection (30o)
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT