STEMI in large RCA with heavy thrombus burden: Treating with a self-apposing stent

Operator(s):

Dariusz Dudek

Institution/Hospital:

Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.

Conflict of interest:

This clinical case study has been submitted with support from STENTYS.

Clinical history:

A 62-year-old female was admitted to the cathlab 2 hours after the onset of symptoms. Prior to admission, the patient was treated with aspirin (300 mg), clopidogrel (600 mg) and unfractionated heparin (5,000 units). An electrocardiogram (ECG) revealed ST-segment elevation in II, III, aVF, V6 leads; ST-segment depression in I, aVL, V1-V2 leads – acute myocardial infarction (AMI) or inferior wall. She had no coronary artery disease (CAD) risk factors and has lupus erythematosus.

Angiography:

Angiography showed mild diffuse disease in the left main coronary artery (LMCA), left anterior descending (LAD) and the circumflex coronary artery (Figure 1). The right coronary artery thrombolysis in myocardial infarction (TIMI) flow grade was 0 (infarct related artery; Figure 2).

Procedure:

TIMI 0/1 flow after passing with guidewire. Launcher (Medtronic) 7F Judkins Right 4.0 guiding catheter was used. Large thrombus burden was evident. Thrombectomy was performed with DIVER CE MAX catheter from Invatec (Medtronic) (2 passages). The result was TIMI 3 flow in a large vessel (approximately 6 mm), but with a large residual thrombus and a clear discrepancy between the proximal and distal reference vessel diameters (Figure 3).

STENTYS coronary stent system was selected: large size indicated for vessels between 3.5–4.5 mm, and which can grow beyond 6 mm; 22 mm length. The stent was positioned over the lesion before deployment, and was deployed from distal to proximal by retracting the outer sheath. Post-dilatation was performed with a 4.5 x 15 mm balloon up to 12 atmospheres.

Conclusion:

1. Complete (> 70%) ST-segment resolution 60 minutes after PCI.
2. TIMI 3 flow in the infarct-related artery.
3. A self-apposing stent can be used when there is residual thrombus after aspiration and in case of diameter discrepancy between proximal and distal vessel.
4. The final result is shown in Figure 4.

The patient was discharged home at day 7 with preserved left ventricular ejection fraction and slight hypokinesia of inferior wall. There were no major adverse cardiac events during 9-month follow-up.

Comment:

Editorial comment from Andreas Baumbach

A new generation of self expanding stents is entering the clinical arena. In this case, the Stentys system is used in a patient presenting with inferior STEMI and an occluded large RCA. A high thrombus burden is documented and the culprit vessel is of large calibre.

The use of a self expanding stent in this scenario has several interesting features that may lead to a clinical benefit.

First, the deployment does not involve a high pressure balloon dilatation. Hence, the often seen no reflow phenomenon in cases with high thrombus burden should be reduced. Second, the expansion continues and follows the vessel size. This should reduce the incidence of late malapposition and underexpansion, which is often seen in procedures carried out for ST elevation infarction. Third, the stent can cover vessel segments with varying vessel diameters and aneurysmatic segments as seen in this case.

The decision to postdilate the stent to achieve a good result is a new development in the recommended deployment technique. The postdilatation certainly improves the angiographic appearance and may lead to a better longterm result by enabling full expansion of the stent without the restriction caused by the underlying, often calcified, stenosis. The Stentys system has been tested in this setting in a small pilot cohort (1). Larger series are underway and will document whether the proposed benefits of this approach to primary angioplasty will translate into improved clinical outcomes.

1. Amoroso G, van Geuns RJ, Spaulding C, Manzo-Silberman S, Hauptmann KE, Spaargaren R, García-García HM, Serruys PW, Verheye S. Assessment of the safety and performance of the STENTYS self-expanding coronary stent in acute myocardial infarction: results from the APPOSITION I study. EuroIntervention. 2011 Aug;7(4):428-36. doi: 10.4244/EIJV7I4A7

Illustrations:

  • Figure 1

    Figure 1: Mild diffuse disease in LMCA, LAD and the circumflex coronary artery.

  • Figure 2

    Figure 2: The right coronary artery TIMI flow grade was 0 (infarct related artery).

  • Figure 3

    Figure 3:

  • Figure 4

    Figure 4: The final result.

This case report does not reflect the opinion of EuroPCR or PCRonline, nor does it engage their responsibility.

4 comments

Kaisu Mikkelsson 06.07.2012

Another option in a vessel this size is not to use a stent in the first place if TIMI 3 flow and ST resolution is achieved by thrombus aspiration and ro rely on prolonged IIb/IIIa and LMWH. Especially in a case like this where there does not seem to be a severe atherosclerotic lesion underlying the thrombus. Did you use the BMS version of the stent? This would be appropriate due to the size of the vessel...

cemil izgi 06.11.2012

Was thrombus aspiration necessary if a self expanding stent would be used in such a case? Was the TIMI 3 flow following thrombus aspiration a result of thrombus aspiration itself?

I think that the TIMI 3 flow following aspiration catheter is primarily because a catheter thicker than the guidewire itself was passed through the lesion rather than aspiration of the thrombus. This is seen in the case. In such a highly thrombotic and ectatic vessel the simplest and the most straightforward approach may be more optimal then thrombus aspiration which in real life experience may be associated with higher risk of retrograde or antegrade embolisation and increased procedure time. My view is that direct stenting, especially with the new self apposing or mesh covered stents, is a viable option in STEMI PCI if flow is established after guidewire passage and the distal vessel can be assessable.

Maged Rizk 02.02.2013

An alternative and effective approach would be to use Angiojet for Rheulytic thrombectomy with or without distal protection device. Since Stentys is not available yet in USA, this would be the only option for such a large thrombus.

Arash Gholoobi 02.09.2013

Well done. I believe that in large ectatic vessels like this self-apposing stent is a perfect choice. I hope if I had it in my lab.