Mechanical thrombectomy options in complex percutaneous coronary interventions

Abstract

Percutaneous coronary interventions (PCI) of thrombus-containing lesions are associated with an increased risk of acute complications and poorer long term vessel patency. Dealing with these vessels provides many technical challenges, especially with the significant risk of coronary no reflow and distal embolization. Pharmacological strategies, including intravenous and intracoronary glycoprotein IIbIIIa inhibitors reduce intracoronary thrombus propagation, improve TIMI flow and are associated with a reduction in adverse event rates. Mechanical strategies (particularly embolic protection and thrombectomy catheters) help to improve coronary blood flow and myocardial perfusion. However, their impact on clinical outcomes is less clear. The use of embolic protection devices is associated with better perfusion, blood flow, and clinical outcomes among patients undergoing saphenous vein graft (SVG) PCI. However, the role for these devices in primary PCI and native coronary artery interventions is uncertain. This study examines the current approaches to manage thrombotic lesions during PCI and reviews the evidence in support of the different mechanical thrombectomy options that are available to the interventional cardiologist.

Clinical Significance of Post-Procedural TIMI Flow in Patients With Cardiogenic Shock Undergoing Primary Percutaneous Coronary Intervention

“…nitric oxide synthase inhibitor) (25) and a novel antiinflammatory agent pexelizumab (a humanized monoclonal antibody that binds the C5 component of complement) (26) have failed to show any benefits in large phase III clinical trials, precluding any recommendations for their use. Similarly, thrombectomy and distal protection devices have failed to demonstrate unequivocal benefits, and their use should at best be individualized at this time (27,28). Finally, although observational studies have supported merits of CABG over primary PCI among these patients (29,30), it is unsettled currently if CABG is associated with better post-procedural TIMI flow grade in IRA than primary PCI for this cohort.…”

Underlying mechanisms of thrombus formation/growth in atherothrombosis and deep vein thrombosis

“…Almost all pathological findings have been obtained from autopsy cases of acute myocardial infarction (AMI) and VTE 10,11 . Technological advances in endovascular devices have made it possible to evaluate the thrombus composition immediately after onset 12 . The findings of aspirated arterial and venous thrombi have provided important information on thrombus formation without medical treatments, the time‐lag after the clinical event, and postmortem artifacts compared with pathological findings obtained from autopsies.…”