Catheterization and Cardiovascular Diagnosis 2054-57 (1990)

Thrombus Aspiration in Acute Myocardial Infarction

Joel K. Kahn, MD, and Geoffrey 0. Hartzler, MD

A 57 yr-old man suffered an in-hospital inferior myocardial infarction 9 yr following cor- onary artery bypass surgery. Emergency cardiac catheterization demonstrated a large, occlusive thrombus in the saphenous vein graft to the right coronary artery. Multiple balloon dilitations failed to lyse the thrombus. A guiding catheter was used to aspirate the thrombus from the graft and there was immediate pain relief.

Key words: coronary angioplasty, myocardial ischemia, reperfusion, coronary artery bypass surgery

INTRODUCTION hospital d when he had the sudden return of substernal

The demonstration by DeWood and colleagues that the vast majority of patients with acute myocardial infarction had thrombotic obstruction of a coronary artery provided the impetus for the development of aggressive therapies of myocardial reperfusion [ 11. Reported experiences with a variety of pharmacologic agents and with direct balloon angioplasty have demonstrated that timely reper- fusion salvages ischemic myocardium leading to im- proved survival and left ventricular function. However, in up to 25% of patients treated with thrombolytic ther- apy, and in a smaller percentage of patients treated with direct balloon angioplasty, the thrombus cannot be dis- rupted and alternative methods of myocardial salvage must be considered. We report a dramatic case of per- cutaneous aspiration of a thrombus in the setting of an acute myocardial infarction.

CASEREPORT

A 57 yr-old man had coronary artery bypass surgery performed in 1980 for three-vessel coronary artery dis- ease. A sequential saphenous vein graft to the left anterior descending and circumflex arteries was constructed and a second vein graft to the distal right coronary artery was placed. The patient did well for 9 yr with exertional angina controlled with medications until June 1989 when he presented to a community emergency room with severe substernal chest pain. Electrocardiography revealed ST- segment elevation inferiorly. He received 1.5 million units of streptokinase intravenously beginning 2 h after the onset of chest pain. There was rapid relief of pain and ST-segment elevation. Creatine kinase enzymes rose to only 231 MIU/ml (normal 11-224 MIU/ml). Intravenous heparin and nitroglycerin were begun. The patient was transferred to our institution on the 2nd hospital d and his medications were continued. He was well until the 4th

chest pain. Electrocardiography showed re-elevation of ST-’segments inferiorly. He was taken urgently to the cardiac catheterization laboratory. Left ventriculography demonstrated severe diaphragmatic hypokinesis, an end- diastolic pressure of 18 mm Hg, and a calculated ejection fraction of 0.42. Injection of the native left coronary circulation demonstrated a left main artery without dis- ease, total occlusion of the mid-left anterior descending artery, and total occlusion of the mid-circumflex artery. The sequential vein graft to the left system was totally occluded at its origin. The native right coronary artery was totally occluded proximally. The vein graft to the distal right coronary artery was intubated with an 8 french Shi- ley JR 4 guiding catheter. Injections demonstrated a large graft that lacked significant occlusions except in its distal aspect where it was totally occluded. Late filming 1 min later demonstrated dye penetration around the occluded segment into a huge thrombus without distal flow (Fig. 1). A 4.0 mm SULP I1 balloon catheter (Advanced Cardio- vascular Systems, Santa Clara, CA) and a 0.014” High Torque Floppy 11 guidewire (Advanced Cardiovascular Systems) were passed into the distal aspects of the graft, and after much manipulation, through the thrombus. Nine balloon inflations for up to 120 s and 7 atm of pressure were performed directly in the thrombus (Fig. 2). Injec- tions demonstrated very slow flow past the thrombus with subtotal narrowing because the huge clot in the distal aspect of the graft had not been disrupted by the balloon

From Cardiovascular Consultants, Inc., Mid America Heart Institute, St. Luke’s Hospital, Kansas City, Missouri.

Received September 18, 1989; revision accepted January 2, 1990

Address reprint requests to Geoffrey 0. Hartzler, M.D., Cardiovas- cular Consultants, Inc., 4320 Wornall Road, Medical Plaza 11-20, Kansas City, MO 641 I 1 .

0 1990 Wiley-Liss, Inc.

Thrombus Aspiration in Myocardial Infarction 55

Fig. 2. Balloon inflation across the occlusive thrombus with a 4.0 mm SULP I1 balloon catheter (Advanced Cardiovascular Systems, Santa Clara, CA).

inflations (Fig. 3). The age and very large burden of the clot despite recent thrombolytic therapy and heparin anti- coagulation were considered to be factors weighing against the probable efficacy of infusing additional lytic agents in the graft. Therefore, the balloon and guidewire

were removed from the guiding catheter, and the guiding catheter was carefully advanced through the vein graft up to the thrombus itself (Fig. 4). Using a 35 cc syringe, the catheter was aspirated for several seconds. Multiple fill- ing defects were seen moving into the guide catheter (Fig. 5) . The guide catheter was removed from the body with constant suction on the syringe to prevent embolization of the extracted material. A rubbery thrombus measuring 7 mm by 4 mm was seen within the syringe itself. The patient experienced immediate relief of chest pain. Repeat graft injections demonstrated absence of the thrombus and reasonable runoff of contrast (Fig. 6 ) . The distal graft anastomosis with the posterior descending artery was then dilated with the balloon catheter for 60 s up to 3 atm. Final injections demonstrated wide patency of the graft with a final stenosis of less than 30% (Fig. 7). Pathologic ex- amination of the specimen demonstrated acute thrombus with laminated fibrin with entrapped red and white blood cells.

The patient did well without elevation of creatine ki- nase enyzmes. On hospital d 9 he underwent repeat cor- onary arteriography. A hazy narrowing at the distai anas- tomosis of the saphenous vein graft to the distal right coronary artery was observed and was redilated. The patient was discharged the next day without recurrent symptoms.

56 Kahn and Hartzler

Fig. 4. The guiding catheter has been advanced through the vein graft to the thrombus. Fig. 6. Selective injection of the vein graft following thrombus

aspiration. Wide patency of the vein graft is appreciated. The distal stenosis remains.

Fig. 5. Following aspiration with a syringe, multiple filling de- fects can be appreciated within the guiding catheter.

This dramatic case highlights a unique approach to the reperfusion of acutely ischemic myocardium. The throm- botic obstruction proved to be resistant to mechanical disruption with the angioplasty balloon despite prior thrombolytic therapy and prolonged intravenous antico- agulation. Lysis was achieved with percutaneous aspira- tion of the thrombotic debris. We have not previously

Fig. 7. Final selective injections following balloon dilatation of the distal vein graft anastomosis. Wide patency with good distal runoff is observed. The patient was asymptomatic at the end of the procedure.

utilized clot aspiration despite an extensive experience with acute infarct intervention, but the maneuver resulted in rapid restoration of antegrade flow and relief of symp- toms. Aspiration of coronary thrombus in the setting of

acute myocardial infarction has been reported only once before, also in a saphenous vein graft [2]. Recent reports also describe cases of aspiration of thrombus resulting from cardiac catheterization and in the peripheral vas- culature [3,4]. These reports taken together highlight the importance of considering percutaneous aspiration of coronary thrombi when they are resistant to mechanical or pharmacologic lysis. Potential benefits must be weighed in each case against the possible risks of embo- lism of the thrombus to distal circulations. Furthermore, the likelihood of guide trauma in tortuous segments prob- ably limits this approach to proximal native coronary arteries and relatively straight segments of saphenous vein grafts.

Thrombus Aspiration in Myocardial Infarction 57

REFERENCES

I . DeWood MA, Spores J , Notske R, Mouser LT, Burroughs R, Golden MS, Lang HT: Prevalence of coronary occlusion during the early hours of transmural myocardial infarction. N Engl J Med

2. Feldman RC: Transcatheter aspiration of a thrombus in an aorto- coronary saphenous vein graft. Am J Cardiol 60:379-380, 1987.

3. Lablanche JM, Fourrier JL, Gommeaux A, Becquart J , Bertrand ME: Percutaneous aspiration of a coronary thrombus. Cathet Car- diovasc Diagn 17:97-98, 1989.

4. Dorros G, Jamnadas P, Lewin RF, Sachdev N: Percutaneous as- piration of a thromboembolus. Cathet Cardiovasc Diagn I7:202- 206, 1989.

3031897-902, 1980.