Novel Use of Dual Guiding Catheters Technique to Prevent Distal Embolization and Slow Flow during PCI of Coronary Stent Thrombosis

Despite having an incidence of 0.5 to 2%, stent thrombosis has an in-hospital mortality of 15% and myocardial infarction (MI) incidence of 67%. Even with the usage of thrombus aspiration devices and microvasculature vasodilators such as nitroprusside, verapamil, adenosine, and Gp2b/3a inhibitors, the angiographic result of percutaneous coronary intervention of coronary stent thrombosis remains frequently suboptimal due to distal embolization and subsequent slow flow. We describe a novel use of dual guide catheter technique, where one guide acts as conduit for thrombus aspiration catheter and the other for distal placement of balloon trap to prevent distal embolization while managing a case of coronary stent thrombosis to improve the angiographic outcome in this scenario.

Comparison of Intracoronary Versus Intravneous Tirofiban in Acute STEMI Patients Undergoing Primary PCI

Objective: This study aimed to investigate the effect of intracoronary tirofiban compared to intravenously administered tirofiban in acute ST-elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PPCI).Methods: This study included 180 patients who were admitted with the diagnosis of acute STEMI and undergoing primary PCI. Patients were randomized into an observation group (n = 90) and control group (n = 90). Both groups received typical treatments, such as aspirin and clopidogrel/ticagrelor. During the procedure, the observation and control groups were administered intracoronary (IC) or intravenous (IV) injections of tirofiban, respectively, followed by an intravenous infusion of tirofiban for 24 hours. Changes in thrombolysis in myocardial infarction (TIMI) flow grading, TIMI myocardial perfusion grade 3 (TMP grade 3), thrombus aspiration, brain natriuretic peptide (BNP) levels, creatine kinase peak and inflammatory factor levels, infarct size, resolution of the sum of ST‐segment elevation (Sum‐STR) two hours after the operation, and cardiac functional parameters were investigated before and/or after treatment and 6 months after discharge. The incidence of major adverse cardiovascular events (MACE) and adverse reactions (AEs) such as bleeding were compared between the two groups.Results: There were no statistically significant differences observed in the indices of BNP, creatine kinase peak, cardiac functional parameters, thrombus aspiration, or incidence of bleeding between the two groups before treatment. Following treatment, TIMI flow grading and TMP grade 3 were improved in the observation group that received intracoronary tirofiban compared to the control group (p = 0.022 and p = 0.014, respectively). Additionally, the Sum‐umi two hours after operation in the observation group was better than that in the control group (p = 0.029). The incidence of MACEs in patients given IC tirofiban administration was lower than that in those given IV tirofiban (p = 0.012). Furthermore, levels of glutamic oxaloacetictransaminase (AST), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and myocardial troponin I (TNI) in the observation group was significantly decreased compared to the control group after five days of treatment (p = 0.039, p = 0.040, p = 0.001, and p = 0.041, respectively). Functional heart parameters including CO and LVEF were significantly improved in the observation group 6 months after discharge.Conclusion: This study found that IC administration of tirofiban in patients with STEMI who underwent PPCI improved TIMI, TMP flow and cardiac function including CO and LVEF 6 months after discharge, and reduced CRP, ESR, and TNI. However, the incidence of bleeding between the two groups was comparable. These findings suggest that IC administration should be applied in certain acute STEMI patients.

766 Distal embolization protection systems. A rare complication

Aims The no reflow phenomenon is a not rare complication that occurs in up to 30% of patients with acute coronary syndrome undergoing myocardial reperfusion by percutaneous coronary intervention. The use of coronary artery thrombus aspiration or distal embolization protection systems has reduced the risk of distal embolization and no-reflow phenomenon. Methods and results We describe the case of a 77 year old female suffering from hypertension presented at our emergency department for inferior STEMI. An urgent coronary angiography was performed, showing a three-vessel coronary artery disease with right coronary artery sub-occluded in the middle segment (culprit lesion), with a voluminous endoluminal minus image, as intracoronary thrombosis. Before performing the coronary angioplasty, a Spider FX3 filter was placed on the distal segment of the right coronary artery; thrombus aspiration was performed, which was ineffective, then angioplasty and Zotarolimus eluting stent implantation in the mid segment of the right coronary artery. After stent implantation, an image of minus was highlighted inside the basket of the filter, as a migrated and incarcerated thrombotic formation; then, the filter was removed. During the removal of the filter, longitudinal crush of the distal portion of the stent is caused, with limitation of the downstream flow, in the absence of haemodynamic instability. The stent was recrossed with Fielder XT guidewire supported by Turnpike LP Microcatheter. Multiple dilations werenperformed with semi-compliant and non-compliant increasing-caliber balloons and then Zotarolimus eluting stent implantation, in partial overlap with the distal portion of the previously implanted stent, with TIMI flow 3. The echocardiogram showed a normal global systolic function, with alterations in regional kinetics. On the 6th day, angioplasty and Zotarolimus eluting stent implantation was performed on the mid-proximal segment of the left anterior descending artery. During the hospitalization the patient was stable and has been discharged in good condition on the ninth day. Conclusions The interest of this case is the evidence of a rare complication related to the use of distal embolization protection system, probably due to an incomplete closure of the filter before removal, due to the high amount of thrombotic material inside it. The rapid recrossing of the stent after the longitudinal crush, the angioplasty and the second stent implantation, led to a quick flow restoration, without haemodynamic and clinical consequences on the patient's outcome.

Manual Thrombus Aspiration and its Procedural Stroke Risk in Myocardial Infarction

Background The previous large‐scale randomized controlled trial showed that routine thrombus aspiration (TA) during percutaneous coronary intervention (PCI) was associated with an increased risk of stroke. However, real‐world clinical evidence is still limited. Methods and Results We investigated the association between manual TA and stroke risk during primary PCI in the OACIS (Osaka Acute Coronary Insufficiency Study) database (N=12 093). The OACIS is a prospective, multicenter registry of myocardial infarction. The primary end point of the present study is stroke at 7 days. A total of 9147 patients who underwent primary PCI within 24 hours of hospitalization were finally analyzed (TA group, n=4448, versus non‐TA group, n=4699 patients). TA was independently associated with risk of stroke at 7 days (odds ratio [OR], 1.92 [95% CI, 1.19‒3.12]; P =0.008) in the simple logistic regression model, while the multilevel random effects logistic regression model with hospital treated as a random effect showed that manual TA was not associated with incremental risk of stroke at 7 days (OR, 0.91 [95% CI, 0.71‒1.16]; P =0.435). The 7‐day stroke risk of manual TA was significantly heterogeneous in different institutions ( P for interaction =0.007). Conclusions Manual TA during primary PCI for patients with acute myocardial infarction was independently associated with the overall increased risk of periprocedural stroke. However, this result was substantially skewed because of institution specific risk variation, suggesting that the periprocedural stroke may be preventable by prudent PCI procedure or appropriate periprocedural management. Registration URL: https://upload.umin.ac.jp/cgi‐open‐bin/ctr_e/ctr_view.cgi?recptno=R000005464 . Unique identifier: UMIN000004575.

Successful endovascular treatment for acute renal artery occlusion

Purpose: We report a case of revascularization for a totally occluded renal artery using endovascular renal thrombus aspiration followed by catheter-directed thrombolysis.Case Report: A 56 years old man presented with sudden onset of severe left-sided abdominal and loin pain for six hours. Urgent computed tomography angiogram showed total occlusion of left renal artery. Emergency selective left renal angiogram and thrombus aspiration using a 5-French Cobra catheter was performed. Catheter-directed thrombolysis with urokinase was initiated after aspiration thrombectomy. Angiogram 24 hours after thrombolysis showed the left renal artery and its segmental branches were successfully revascularized. Patient was on anticoagulation after operation and his renal function recovered well.Conclusion: Percutaneous aspiration thrombectomy combined with intra-arterial local fibrinolysis are effective in the salvage of renal function.