Plaque Gruel of Atheromatous Coronary Lesion May Contribute to the No-Reflow Phenomenon in Patients With Acute Coronary Syndrome

Abstract

Background-No-reflow associated with direct angioplasty (PCI) of patients with acute coronary syndromes (ACS) is associated with unfavorable results. Methods and Results-We used a new thrombectomy device to treat 51 lesions in 48 consecutive ACS patients (40 male and 8 female; mean age 63 years) and conducted a microscopic analysis of aspirates and blood samples retrieved from the culprit coronary artery. The first aspirate was collected before PCI and the second was collected separately after percutaneous transluminal coronary angioplasty or stenting, including samples from the no-reflow lumen. Light microscopy showed that the materials obtained from the pre-PCI aspiration consisted of thrombus in 37.5%, thrombus and atheroma in 35.0%, and atheromatous plaque in 27.5%. The materials collected from the post-PCI aspiration were thrombus in 8.3%, thrombus and atheroma in 41.7%, and atheromatous plaque in 50.0%. We then compared the 9 lesions (19.1%) with no-reflow to those without no-reflow. There was no difference in the pre-PCI aspirates. However, after PCI, there was more atheromatous plaque retrieved from patients with no-reflow (PϽ0.001) as well as significantly more platelet and fibrin complex, macrophages, and cholesterol crystals in the blood aspirated from no-reflow cases. Aspiration of these elements improved the no-reflow in 7 of 9 lesions to TIMI-3 flow. Conclusions-No-reflow after angioplasty may be caused by gruel that formed from an atheroma attributable to mechanical plaque disruption during intervention.

<b>Percutaneous Coronary Arterial Thrombectomy for Acute Myocardial Infarction Reduces No-Reflow Phenomenon and Protects Against Left Ventricular Remodeling Related to the Proximal Left Anterior Descending and Right Coronary Artery</b>

“…Fourth, we did not evaluate the other causes of no-reflow phenomenon, such as reperfusion injury, microvascular spasm, endothelial cell damage, tissue edema, platelet aggregation, neutrophil clots, and atheromatous plaque plugging of the microvessels. 14,36,40,41) We believe that these other causes contributed to the controversial results of previous thrombectomy studies. 13,14,36,40,42) Fifth, GP IIb/IIIa inhibitors or abciximab are not available in Japan, and therefore the results of this study will not be considered to be world-standard of care during PCI.…”

Plaque Instability Frequently Occurs Days or Weeks Before Occlusive Coronary Thrombosis

“…Thrombectomy was performed with the Rescue PT system (Boston Scientific), as described previously. 6,11 Typically, several suctions at the site of the occlusion were performed after smooth introduction and initial passage of the flexible, soft catheter. Aspirated blood and intracoronary material were collected in the collection bottle, which was provided with a filter.…”

“…4,5 The exact time course of events and the frequency of occurrence of older thrombus in patients with STEMI is, however, largely unknown. The presence of intracoronary thrombus and atheromatous plaque constituents may lead to distal embolization and the "no-reflow" phenomenon after percutaneous coronary intervention (PCI), 6 both associated with poor clinical outcome. [7][8][9][10] Thus, as an adjunct to primary PCI for acute STEMI, thrombectomy devices were developed to remove the occluding intracoronary material before balloon dilatation and stent placement.…”

Enhanced Expression of Hemoglobin Scavenger Receptor CD163 in Accumulated Macrophages Within Filtered Debris Between Acute Coronary Syndromes and Stable Angina Pectoris

“…30) Second, the present study had a relatively small sample size and excluded patients whose debris was not collected by Filtrap ® . Third, in VH-IVUS studies, the presence of thrombi in ACS lesions may influence the plaque composition.…”