CASE20240715_001
Challenging Massive Thrombosis Withing Right Coronary Artery in Acute Coronary Syndrome
By Teh-Kuang Sun
Presenter
Teh-Kuang Sun
Authors
Teh-Kuang Sun1
Affiliation
Cheng Ching Hospital, Taiwan1,
View Study Report
CASE20240715_001
ACS/AMI - ACS/AMI
Challenging Massive Thrombosis Withing Right Coronary Artery in Acute Coronary Syndrome
Teh-Kuang Sun1
Cheng Ching Hospital, Taiwan1,
Clinical Information
Relevant Clinical History and Physical Exam
53 y/o male police officer, with past history including type 2 DM, hyperlpidemia, HCVD and Obese class I (BMI 30.5). No smoker. Recent peptic ulcer disease with bleeding. On 2022/5/4, he had new onset of dull and pressure like chest pain, involving epigastric area with nauceas, no cold sweating. Palpitation and dizziness was associated. He went to our ER for help as symptoms persisted to 5/5.
Relevant Test Results Prior to Catheterization
Laboratory data showed no major abnormality except serum Troponin I 8399.9 ng/L (normal : <19) . Electrocardiogram: sinus tachycardia, Q wave on leads III AVF with non specific ST-T change. CXR: borderline cardiomegaly.
Relevant Catheterization Findings
Left Main (LM) trunk: patentLeft anterior descending artery (LCX) and Left circumflex artery (LCX): Patent. Diffuse atherosclerosis without significant stenosis. Slow coronary flowRight coronary artery (RCA): total occlusion from proximal RCA due to massive thrombosis. TIMI flow 0Collateral circulation: from distal LAD and septal branches to distal RCA, PL and PDA branches.
RCA RAO THROMBUS 202205093f.AVI
RCA LAO THROMBUS 202205093L.AVI
202205092f LCA RAO CRANIAL.AVI
RCA RAO THROMBUS 202205093f.AVI RCA LAO THROMBUS 202205093L.AVI 202205092f LCA RAO CRANIAL.AVIInterventional Management
Procedural Step
PTCA procedure was performed for RCAGuiding Catheter: 6F Mini-Kimny. PTCA wire: Asahi Sion, the wire crossed the lesion without major resistance.Aspiration thrombectomy: ProntoV3 catheter aspiration four times from distal RCA to middle RCA. Large amount of thrombus remained with impaired flow. PTCA balloon dilatation: 3.0x15 Balloon, dilatation with 4-8 atm/ 30-20 seconds, to middle and distal segments of RCA, with intention to regain flow. TIMI II flow was regainedSignificant amount of old thrombus remained within RCA despite of multiple attempts with aspiration thrombectomy and balloon angioplasty.
RCA ASPIRATION 2022050914L.AVI
RCA FINAL 2022050918L.AVI
AngioJet thrombectomy system was not available in our cath lab. Due to peptic ulcer disease with bleeding in recent months, thrombolytic therapy was not employed.
Warfarin 5-10mg po qd was continued for the following 6 months. Coronary angiography follow up was arranged. No thrombus remained within RCA.
RCA ASPIRATION 2022050914L.AVI RCA FINAL 2022050918L.AVICase Summary
In the PCI era, study related to use of warfarin during and post AMI showed inconsistent results, showing some outcome advantage while use in combination with aspirin. In this patient, use of warfarin because of following considerations: 1. The remained intracoronary thrombus amount was unable to be removed mechanically 2. Recent history of peptic ulcer causing concern on the use of thrombolytics 3. feasibility of control the anticoagulant effect through INR. Despite the successful thrombolysis from the primary event, even then, more clinical studies to support this strategy is needed.