Author + information
- Michael Mao-Chen Liang1,
- Ramkumar Sekar1,
- Syed Saqib Imran1,
- Teck-Kee Ang1,
- Khang-Leng Leow1 and
- Brian Khoo1
An acute coronary syndrome associated with significant thrombus burden in the culprit coronary artery is a challenge to interventional cardiologists. In this study, the patients with high thrombus burden and unsatisfactory thrombectomy at the index procedure were managed with a short period of intense anticoagulation therapy. Coronary angiography with or without percutaneous coronary intervention (PCI) was performed prior to hospital discharge to document final TIMI (thrombolysis in myocardial infarction) flow and coronary outcomes.
Between 1 Jun 2014 and 31 Oct 2016, 17 patients presented with acute coronary syndrome with heavy thrombus burden and an index procedure failed to achieve satisfactory thrombectomy requiring Intense-anticoagulation therapy. Dual antiplatelet therapy was administered for all patients unless contraindicated. Glycoprotein IIb/IIIa inhibitor and/or subcutaneous Enoxaparin (1 mg/kg) were administered during the hospital stay. A follow-up angiography with or without angioplasty was performed at the end of treatment.
Of the 17 patients, the mean age was 53 ± 8 years-old and 94% were male. ST-elevation myocardial infarction (STEMI) accounts for 71% of the presentations and 29% for non-ST-elevation myocardial infarction (NSTEMI). The culprit vessel was right coronary artery (RCA) in 76% of the cases, 18% in left circumflex artery (LCX) and 6% in left anterior descending artery (LAD). During the index procedure, TIMI (Thrombolysis in Myocardial Infarction) thrombus grade was documented: 12%cases were Grade III, 35% Grade IV and 53% Grade V. Ectatic coronary artery was observed in 24% of the cases. TIMI 0, I, II and III flow was achieved at end of the index procedure in 6%, 41%, 24% and 29% respectively, following thrombectomy. All patients were on Aspirin with 71% on clopidogrel and 29% on Ticagrelor. They were started on anti-coagulation therapy with the median duration of 6 days (range 4-8). Glycoprotein IIb/IIIa was used in 71% of cases for the first 24 to 48 hours. Subcutaneous enoxaparin was used for all patients. There were no bleeding complications or inpatient mortality reported during the hospital stay. Re-look coronary angiography after anti-coagulation therapy showed TIMI III flow in 65% (p=0.04) of the cases with 41% required additional stenting.
Intense anti-coagulation therapy in heavy Thrombus-burden coronary arteries with unsatisfactory thrombectomy is safe with high success rate in reducing thrombus burden and improves coronary flow. Further study is required to determine optimum anticoagulation duration and regime.