A mechanism for stroke complicating thrombus aspiration

Abstract

We propose a mechanism of how stroke may be caused by thrombus aspiration during primary percutaneous coronary intervention (PPCI), and how it may be technique-dependent. Two recent meta-analyses report increased risk of stroke in patients undergoing routine thrombus aspiration during STEMI and the value of this technique has been controversial. The mechanism of stroke has not been fully explained. This case demonstrates 2 mechanisms by which aspiration might cause thrombus embolization. We recommend that if thrombus aspiration is performed during PPCI for STEMI, it should be done selectively and carefully. It is prudent to make sure the guide catheter tip is not free in the aorta when the aspiration catheter is withdrawn, to maintain suction on the aspiration catheter as it is withdrawn (particularly if the aspiration port seems to be obstructed), and to aspirate the guide catheter after the aspiration catheter is removed to capture any fragments of thrombus that remain in the guide catheter. © 2016 Wiley Periodicals, Inc.

AngioJet rheolytic thrombectomy in patients with thrombolysis in myocardial infarction thrombus grade 5: an observational study

“…However, the effectiveness of manual thrombus aspiration is susceptible to operating techniques. The increased risk of stroke in the manual thrombus aspiration group might be pertinent to the detachment of thrombus from aspiration catheter 8 . Mechanical thrombus aspiration is accomplished with high velocity saline jets leading to a low-pressure zone (Bernoulli effect), which is more effective in thrombus removal than manual aspiration.…”

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“…The risk of systemic embolization can be reduced with improved technique. For instance, a thrombus that cannot be fully aspirated is at risk of fracturing and shedding fragments or entering still intact into the systemic vasculature, particularly if suction is not maintained in the aspiration catheter, and the guiding catheter is not engaged in the artery as the aspiration catheter is withdrawn (24). Technical tips such as advancing the guiding catheter tip in the coronary artery and maintaining negative pressure on the aspiration catheter as it is withdrawn, or allow a retrograde blood spill-over from the guiding catheter after the aspiration catheter is removed are small technical measures but important to improve the safety of this procedure.…”

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“…For instance, a thrombus that cannot be fully aspirated is at risk of fracturing and shedding fragments or entering still intact into the systemic vasculature, particularly if suction is not maintained in the aspiration catheter, and the guiding catheter is not engaged in the artery as the aspiration catheter is withdrawn. 24 Interestingly, all three trials included in the meta-analysis only evaluated manual thrombus aspiration. While more complex (i.e., mechanical) devices might be more effective in extracting atherothrombotic particles from the coronary arteries, they are bulkier and require selected coronary anatomies.…”