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TCTAP C-128 Acute Brachial Artery Thrombosis Associated with Heparin-induced Thrombocytopenia After Transradial Coronary Intervention
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
S247
TCTAP C-128 Acute Brachial Artery Thrombosis Associated with Heparin-induced Thrombocytopenia After Transradial Coronary Intervention Yisik Kim,1 Jei Keon Chae,1 Soo-Kyeong Song,1 Ji-Young Yoon,1 Laeyoung Jung,1 Sun-Hwa Lee,1 Sang-Rok Lee,1 Kyoung-Suk Rhee,1 Won-Ho Kim,1 Jae-Ki Ko1 1 Chonbuk National University Hospital, Korea (Republic of) [CLINICAL INFORMATION] Patient initials or identifier number. LOR, 1267524 Relevant clinical history and physical exam. A 74-year-old woman presented to the emergency room with chest discomfort and shortness of breath. She had no history of chronic medical illness. On admission, her blood pressure was 140/90 mmHg with a pulse of 88 beats per minute. Relevant test results prior to catheterization. The electrocardiography showed Q wave and T wave inversion in precordial leads. Chest x-ray showed pulmonary venous congestion on both lung fields. Transthoracic echocardiography (TTE) revealed an impaired LV ejection fraction by 33% and multiple RWMA. Cardiac troponin I (cTnI) was positive. She was diagnosed with non ST-elevation MI. Conventional medical therapy that include a loading dose of aspirin (300 mg), clopidogrel (600 mg) and unfractionated heparin was applied before PCI. Relevant catheterization findings. Coronary angiography (CAG) showed CTO of RCA and thrombotic near total occlusion of mid LAD. At first, PCI to LAD was performed with implantation of one drug eluting stent (DES) 3.028 mm (Xience XpeditionÒ , Abbott Vascular, USA) via right radial artery. After procedure, unfractionated heparin was continued with adequate therapeutic aPTT range and CTO-RCA was deferred for stage PCI.
Case Summary. In retrieving a dislodged stent, the mechanism of dislodgement, the presence of wire in the dislodged stent and the position of stent in relations to coronary arteries, aorta and guiding catheter were to be considered. We believed that a segment of diagonal wire went under stent strut at proximal LAD and therefore the new stent on diagonal wire was trapped with proximal LAD stent. Gripping force from trapping balloon inside guiding catheter failed to hold the deformed and elongated stent. Snares could provide strong pulling force but coronary snares failed also. EN Snare with interlaced loops finally caught the stent. We should have a emergency backup by setting up another guiding catheter.
[INTERVENTIONAL MANAGEMENT] Procedural step. On hospital day (HD) #4, the patient developed severe pain and discoloration on right first and second digits (Fig 2A). Physical examination revealed diminished right brachial and absent radial pulses. CT angiography revealed total occlusion of distal right brachial artery (Fig 2B). Emergent catheterization was performed through right femoral artery and angiography documented thrombotic total occlusion of the right brachial artery. Repetitive thrombectomy and trancatheter thrombolysis with urokinase was performed (Fig 3A). Next day, however, the pain and discoloration of digits was increasing, follow-up angiogram showed re-occlusion of right brachial artery (Fig 3B). We performed repetitive thrombus aspiration and balloon angioplasty (Fig 3C, 3D). Final angiogram showed improved distal run-off (Fig 3E) and we decided to continue unfractionated heparin therapy for 3 days. After PTA, the pulses were improved to near-normal and cyanosis was diminished. On HD #8, stage PCI to CTO-RCA was performed successfully via right femoral artery. However, after stage PCI, on HD #9, platelet count of 82 x x103 /mL was documented. Platelet count on admission was 219 x103 /m L. Because 4Ts score 7 suggested high probability of heparin-induced thrombocytopenia thrombosis (HIT/T), unfractionated heparin was discontinued and anticoagulation with fondaparinux was started. Platelet count was declined to 3.6 x103 /mL on HD #15.
S248
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
TCTAP C-129 Once Naughty Child Complicates ‘Right Main’ Monique Priscilla Fransiska Rotty,1 Johan Senihardja,1 Soetandar Widjaja,1 Hendro Adi Kuncoro,1 Rizki Francis Pandelaki,1 Yosua Arthur Iskandar,1 Benny Mulyanto Setiadi,1 Bambang Budiono,2 Edmond Jim,1 Janry Anton Pangemanan,1 Agnes Lucia Panda1 1 Sam Ratulangi University Manado, Indonesia; 2Awal Bros Makassar Hospital, Indonesia [CLINICAL INFORMATION] Patient initials or identifier number. Mrs. S. S. Relevant clinical history and physical exam. A 70 year-old female was admitted with stable angina pectoris. After received medical treatment for two months in outpatient cardiology clinic, she is still complaining chest pain radiating to her back. She has a previous history of hypertension, hypercholesterolemia, and non-hemorrhagic stroke. Physical examination was normal.
Case Summary. On HD #23, platelet count recovered to 133 x103 /mL and she was discharged home on triple antithrombotic therapy with aspirin, clopidogrel and warfarin. In this case, we successfully managed HIT/T induced digital ischemia that is a serious medical complication, with non-heparin anticoagulant and transluminal angioplasty. She did not develop thrombocytopenia until 5 days after her thrombosis. Heparin induced thombocytopenia should be suspected clinically in patients with recent heparin exposures, those patients who develop not only thrombocytopenia but also otherwise unexplained thrombosis regardless of the platelet count.
S247
TCTAP C-128 Acute Brachial Artery Thrombosis Associated with Heparin-induced Thrombocytopenia After Transradial Coronary Intervention Yisik Kim,1 Jei Keon Chae,1 Soo-Kyeong Song,1 Ji-Young Yoon,1 Laeyoung Jung,1 Sun-Hwa Lee,1 Sang-Rok Lee,1 Kyoung-Suk Rhee,1 Won-Ho Kim,1 Jae-Ki Ko1 1 Chonbuk National University Hospital, Korea (Republic of) [CLINICAL INFORMATION] Patient initials or identifier number. LOR, 1267524 Relevant clinical history and physical exam. A 74-year-old woman presented to the emergency room with chest discomfort and shortness of breath. She had no history of chronic medical illness. On admission, her blood pressure was 140/90 mmHg with a pulse of 88 beats per minute. Relevant test results prior to catheterization. The electrocardiography showed Q wave and T wave inversion in precordial leads. Chest x-ray showed pulmonary venous congestion on both lung fields. Transthoracic echocardiography (TTE) revealed an impaired LV ejection fraction by 33% and multiple RWMA. Cardiac troponin I (cTnI) was positive. She was diagnosed with non ST-elevation MI. Conventional medical therapy that include a loading dose of aspirin (300 mg), clopidogrel (600 mg) and unfractionated heparin was applied before PCI. Relevant catheterization findings. Coronary angiography (CAG) showed CTO of RCA and thrombotic near total occlusion of mid LAD. At first, PCI to LAD was performed with implantation of one drug eluting stent (DES) 3.028 mm (Xience XpeditionÒ , Abbott Vascular, USA) via right radial artery. After procedure, unfractionated heparin was continued with adequate therapeutic aPTT range and CTO-RCA was deferred for stage PCI.
Case Summary. In retrieving a dislodged stent, the mechanism of dislodgement, the presence of wire in the dislodged stent and the position of stent in relations to coronary arteries, aorta and guiding catheter were to be considered. We believed that a segment of diagonal wire went under stent strut at proximal LAD and therefore the new stent on diagonal wire was trapped with proximal LAD stent. Gripping force from trapping balloon inside guiding catheter failed to hold the deformed and elongated stent. Snares could provide strong pulling force but coronary snares failed also. EN Snare with interlaced loops finally caught the stent. We should have a emergency backup by setting up another guiding catheter.
[INTERVENTIONAL MANAGEMENT] Procedural step. On hospital day (HD) #4, the patient developed severe pain and discoloration on right first and second digits (Fig 2A). Physical examination revealed diminished right brachial and absent radial pulses. CT angiography revealed total occlusion of distal right brachial artery (Fig 2B). Emergent catheterization was performed through right femoral artery and angiography documented thrombotic total occlusion of the right brachial artery. Repetitive thrombectomy and trancatheter thrombolysis with urokinase was performed (Fig 3A). Next day, however, the pain and discoloration of digits was increasing, follow-up angiogram showed re-occlusion of right brachial artery (Fig 3B). We performed repetitive thrombus aspiration and balloon angioplasty (Fig 3C, 3D). Final angiogram showed improved distal run-off (Fig 3E) and we decided to continue unfractionated heparin therapy for 3 days. After PTA, the pulses were improved to near-normal and cyanosis was diminished. On HD #8, stage PCI to CTO-RCA was performed successfully via right femoral artery. However, after stage PCI, on HD #9, platelet count of 82 x x103 /mL was documented. Platelet count on admission was 219 x103 /m L. Because 4Ts score 7 suggested high probability of heparin-induced thrombocytopenia thrombosis (HIT/T), unfractionated heparin was discontinued and anticoagulation with fondaparinux was started. Platelet count was declined to 3.6 x103 /mL on HD #15.
S248
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 67, NO. 16, SUPPL S, 2016
TCTAP C-129 Once Naughty Child Complicates ‘Right Main’ Monique Priscilla Fransiska Rotty,1 Johan Senihardja,1 Soetandar Widjaja,1 Hendro Adi Kuncoro,1 Rizki Francis Pandelaki,1 Yosua Arthur Iskandar,1 Benny Mulyanto Setiadi,1 Bambang Budiono,2 Edmond Jim,1 Janry Anton Pangemanan,1 Agnes Lucia Panda1 1 Sam Ratulangi University Manado, Indonesia; 2Awal Bros Makassar Hospital, Indonesia [CLINICAL INFORMATION] Patient initials or identifier number. Mrs. S. S. Relevant clinical history and physical exam. A 70 year-old female was admitted with stable angina pectoris. After received medical treatment for two months in outpatient cardiology clinic, she is still complaining chest pain radiating to her back. She has a previous history of hypertension, hypercholesterolemia, and non-hemorrhagic stroke. Physical examination was normal.
Case Summary. On HD #23, platelet count recovered to 133 x103 /mL and she was discharged home on triple antithrombotic therapy with aspirin, clopidogrel and warfarin. In this case, we successfully managed HIT/T induced digital ischemia that is a serious medical complication, with non-heparin anticoagulant and transluminal angioplasty. She did not develop thrombocytopenia until 5 days after her thrombosis. Heparin induced thombocytopenia should be suspected clinically in patients with recent heparin exposures, those patients who develop not only thrombocytopenia but also otherwise unexplained thrombosis regardless of the platelet count.