An 84-year-old man presented to the emergency department with severe chest pain that had begun three hours earlier. He was a heavy smoker with a history of hypertension. On examination, his blood pressure was 120/64 mm Hg, his pulse was regular at 100 beats/min, and his respiratory rate was 20 breaths/min. The remainder of the physical examination was unremarkable. An electrocardiogram showed a sinus rhythm with ST-segment elevation in leads II, III and aVF. Blood chemistry results showed a creatine kinase (CK) level of 184 (normal 40–290) U/L, a CK MB fraction of 6 (normal < 7) U/L and a troponin I level of 0.32 (normal < 0.5) μg/L. Coronary angiography done emergently showed two-vessel disease. The right coronary artery (the infarct-related vessel) was filled with thrombus-containing lesions over the middle portion (Figure 1A), with evidence of partial reperfusion (Thrombolysis in Myocardial Infarction [TIMI] grade 2 flow). After placement of a guide wire, the QXT extraction catheter (Vascular Solutions, Inc., Minnesota, USA) was advanced into the affected area, and a large red thrombus was aspirated. The thrombus, about 6 cm in length (Figure 1B), was found to match the filling defect on the angiography. After angioplasty, angiography showed complete reperfusion (TIMI grade 3 flow) (Figure 1C). The patient was discharged from hospital six days later.
The benefit of timely reperfusion by primary coronary intervention has been confirmed in acute ST-segment elevation myocardial infarction.1 However, embolization of remaining atherothrombotic debris can lead to microvascular obstruction and worse clinical outcomes.2 Several clinical trials have shown that thrombus aspiration can be performed successfully in most patients with acute ST-segment elevation myocardial infarction, and it results in better reperfusion and clinical outcomes than achieved with conventional primary coronary intervention.3,4 Recent guidelines support its use in specific circumstances, such as in patients with short ischemic times and large thrombus burden.1 Potential adverse events include endothelial damage from forceful aspiration and trauma to tortuous proximal vessels from the aspiration device.3
Footnotes
-
This article has been peer reviewed.
-
Competing interests: None declared.