Thrombus Embolisation: Prevention is Better than Cure

Abstract

Thrombus embolisation complicating primary percutaneous coronary intervention in ST-elevation myocardial infarction is associated with an increase in adverse outcomes. However, there are currently no proven recommendations for intervention in the setting of large thrombus burden. In this review, we discuss the clinical implications of thrombus embolisation and angiographic predictors of embolisation, and provide an update of current evidence for some preventative strategies, both pharmacological and mechanical, in this setting.

Large intracoronary thrombus and its management during primary PCI

“…1 demonstrates the proposed algorithm for management of large thrombus burden during primary PCI. 58

Fig. 1 Proposed algorithm for management of large thrombus burden during primary PCI (modified from reference 58).

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Thin-strut bioresorbable-polymer sirolimus-eluting stent use for an optimal result of rescue coronary angioplasty in acute myocardial infarction failed thrombolytic therapy: the Bangladesh National Heart Foundation Annual Conference OCT-assisted live case

“…This should be paired with optimal stent use to achieve best outcomes in vessel lumen reconstruction and long-term clinical outcomes. Thrombolysis in myocardial infarction residual thrombus grade [7] was 2 out of 5. After i.v.…”

“…However, it is methodologically incorrect to assign to thrombectomy strokes occurring 48 h to 6 months after thrombectomy-assissted primary percutaneous coronary intervention (PCI) (note 37 late strokes in the thrombectomy arm vs. 23 late strokes in the PCI alone arm of, respectively, 5033 and 5030 patients in the TOTAL study [4]) making the study conclusion essentially flawed (for the TASTE study fundamental design flaw, including enrollment limited to patients who would not require or benefit from thrombectomy in the operator's opinion [5]). Because thrombus embolism aggravates myocardial injury [2,3,6,7], aspiration thrombectomy should remain A -proximal left anterior descending (LAD) occlusion (arrow). B -thrombus aspiration (second run, note contrast stagnation) using Export 6F (Medtronic) aspiration catheter (arrow); note white and red thrombi removed from the infarct-related artery, as shown in the aspiration system's basket (B, inset).…”

“…an essential consideration in primary angioplasty in acute myocardial infarction [5,[7][8][9], similar to the fundamental role played by thrombectomy in acute ischemic stroke interventions [10]. This should be paired with optimal stent use to achieve best outcomes in vessel lumen reconstruction and long-term clinical outcomes.…”

“…However, it is methodologically incorrect to assign to thrombectomy strokes occurring 48 h to 6 months after thrombectomy-assissted primary percutaneous coronary intervention (PCI) (note 37 late strokes in the thrombectomy arm vs. 23 late strokes in the PCI alone arm of, respectively, 5033 and 5030 patients in the TOTAL study [ 4 ]) making the study conclusion essentially flawed (for the TASTE study fundamental design flaw, including enrollment limited to patients who would not require or benefit from thrombectomy in the operator’s opinion [ 5 ]). Because thrombus embolism aggravates myocardial injury [ 2 , 3 , 6 , 7 ], aspiration thrombectomy should remain an essential consideration in primary angioplasty in acute myocardial infarction [ 5 , 7 – 9 ], similar to the fundamental role played by thrombectomy in acute ischemic stroke interventions [ 10 ]. This should be paired with optimal stent use to achieve best outcomes in vessel lumen reconstruction and long-term clinical outcomes.…”