Lesion-directed administration of alteplase with intracoronary heparin in patients with unstable angina and coronary thrombus undergoing angioplasty

Abstract

Percutaneous coronary revascularization in patients with unstable angina and coronary thrombus carries a high complication rate. A new strategy to reduce thrombus burden before revascularization was tested in a multicenter prospective trial. Patients with unstable angina and coronary thrombus (n = 45) received alteplase through an infusion catheter at the proximal aspect of the target lesion and concomitant intracoronary heparin via a standard guiding catheter. Angiography was performed before and after lesiondirected therapy and post-intervention. Systemic fibrinogen depletion and thrombin activation were not observed, while fibrinolysis was evident for 2 4 hr after treatment. Target lesion stenosis did not change significantly after lesion-directed therapy, but thrombus score was reduced, particularly among patients who had large thrombi (mean 2.2 vs. 1.6, P = 0.02). Revascularization was successful in 89% of patients. Median final stenosis was 30% and mean final thrombus score was 0.4. Complications included recurrent ischemia (llY0), MI (7%), abrupt closure (7%), severe bleeding (4%), and repeat emergency angioplasty (2%). Patients with overt thrombus appeared to derive the most angiographic benefit from lesion-directed alteplase plus intracoronary heparin. Later revascularization was highly successful. This strategy may be a useful adjunct to percutaneous revascularization for patients with unstable angina and frank intracoronary thrombus.

Successful Revascularization of Coronary Artery Occluded by Massive Intracoronary Thrombi with Alteplase and Percutaneous Coronary Intervention

“…For instance, intracoronary t-PA registry investigators found significant improvements in the coronary TIMI flow grade and thrombus dissolution with intracoronary t-PA in 198 patients (206 cases) 9) . Gurbel PA et al found that lesion-directed delivery of alteplase resulted in more prolonged local thrombolysis and thrombus score reduction in 45 unstable angina patients with coronary thrombus 10) . Recently, Kelly RV et al reported that the administration of intracoronary thrombolytics (tenecteplase) in complex PCI after the onset of thrombotic complications is safe and may even improve the success rate in PCI complicated by thrombus in the study of 34 patients (22 with acute ST elevation MI, 4 with rescue PCI, 6 with non-ST elevation MI, and 2 during elective PCI) 11) .…”

Endothelial Cell Apoptosis is Responsible for the Formation of Coronary Thrombotic Atherosclerotic Plaques

“…1. Study protocol performed blindly by two experienced interventional cardiologists to record a thrombotic score as followings: 0, no thrombus; 1, intraluminal haziness; 2, definite thrombus with its diameter or length < 0.5 times normal vessel diameter; 3, 0.5-2 times; 4, > 2 times (Gurbel et al 1996). Angiographic overt thrombosis was defined as having thrombotic scores of 3-4.…”

Very Early versus Early Invasive Strategy after Successful Thrombolysis in Patients with ST Segment Elevation Myocardial Infarction

“…Angiographic data: Coronary angiography and subsequent needed intervention for the culprit vessel was done for each patient according to the index time of each study group with the following data obtained: Culprit and other vessel affection, site of the lesion, type of the lesion according to AHA/ACC classification system into 3 types A, B and C, [12] the degree of stenosis, thrombus burden, [13] TIMI flow, [14] and myocardial blush grade (MBG) [15] were assessed. N.B.…”