Catheterization and Cardiovascular Diagnosis 27:49-51 (1992)
Aspiration of a Mobile Thromboembolus From Saphenous Vein Graft Harry M. Cohen, MD, FACC, and Jay H. Kleiman, MD, FACC An 81-year-old woman who was 4 years post Svessel coronary artery bypass graft (CABG) surgery suffered a non-Q-wave myocardial infarction. Angiography revealed the recent occlusion of a saphenous vein graft (SVG) to an obtuse marginal coronary artery. Five days following failure of intragraft urokinase and systemic heparinization to recanalize the SVG, balloon angioplasty was undertaken. A mobile thrombus was observed to migrate spontaneouslyin a retrograde manner in the SVG and was removed during PTCA by aspiration through the guiding catheter. o 1992 wiiey-~iss,inc. Key words: non-Q MI, saphenous vein bypass graft, intragraft urokinase, percutaneous aspiration of mobile thrombus, PTCA of occluded SVG
INTRODl CTlO
a 90% ostial right coronary narrowing, and a critical mid right coronary artery lesion were demonstrated. The saThe definitive transcatheter therapeutic modality for phenous vein bypass graft (SVG) to the right coronary effectively dealing with thrombus in a native coronary artery was occluded at its origin. The SVG to the obtuse artery or saphenous vein bypass graft (SVG) has yet to be marginal was also occluded with filling defects in its defined. Numerous mechanical modalities (balloon anproximal portion compatible with thrombus. The SVG to gioplasty , atherectomy, and intracoronary laser applicathe LAD coronary artery was still widely patent and tions), as well as pharrnacologic interventions (systemic filled the distal LAD, which in turn collateralized the heparinization, thrombolytic therapy), both alone and in previously grafted obtuse marginal branch of the left circombination, have been tried with variable success. Litcumflex coronary system. Left ventricular function tle has been reported in the literature, however, about showed moderate global impairment. At the time of corstrategies to deal with a mobile thrombus, whether in a onary angiography, 10,OOOU heparin were given intranative coronary artery or in a saphenous vein bypass venously and 500,000 U urokinase were infused through graft. We report a technique utilized to deal with a moa diagnostic coronary catheter directly into the occluded bile thrombus that was observed to migrate spontaneSVG to the obtuse marginal branch. Immediately followously in a retrograde manner in a saphenous vein bypass ing this selective urokinase infusion, a modest decrease graft. in the extent of filling defects was noted in the proximal vein graft. No antegrade flow beyond the point of occlusion was established. CASE REPORT The patient was brought back to the cardiac catheterization laboratory 5 days following her first angiographic An 81-year-old white female underwent coronary arprocedure due to refractory anginal pain in spite of contery bypass graft surgery (CABG) in 1987 with 3 sepatinued treatment with intravenous heparin and nitroglycrate saphenous vein bypass grafts placed to her LAD, left erine. Repeat angiography was essentially unchanged. circumflex, and right coronary arteries. The patient reSVG to the LAD again demonstrated Angiography of the mained angina free until July 1991. In September 1991 she was hospitalized with recurrent anginal chest pain and sustained a non-Q wave myocardial infarction. She was stabilized with intravenous heparin and nitroglycer- From the St. Joseph Hospital and Medical Center and Northwestern ine, aspirin, and procardia. The patient underwent car- University Medical School, Chicago, Illinois. diac catheterization on the second day of her hospitalReceived December 7, 1991; revision accepted April 7, 1992. ization. Coronary angiography revealed a 90 percent left main Address Reprint Requests to Harry M. Cohen, M.D.,Northside Carlesion with an adjacent 95% ostial left circumflex coro- diology Group, Ltd., 2800 North Sheridan Road, Suite 606,Chicago, nary artery stenosis. A 100% occlusion of the mid LAD, IL 60657. 0 1992 Wiley-Liss, Inc.
50
Cohen and Kleiman
Fig. 1. Angiographic appearance of the occluded saphenous vein graft to the obtuse marginal branch in an 81-yearold woman 7 days following an acute non-Q wave MI. Five days earlier, urokinase had been selectively infused into the graft. Note the filling defect consistent with thrombus. This was later observed to migrate spontaneously (double arrowhead). Residual thrombus that remained stable without migration is present prior to the point of total occlusion (single arrowhead).
collateral flow to the obtuse marginal branch of the circumflex coronary artery from the distal LAD. It was felt that the patient’s continuing refractory anginal pain was due to the inadequacy of this collateral flow and that recannulization of the recently occluded SVG to this marginal coronary branch would likely reverse her recurring clinical ischemia. Initial attempts to recannulize the occluded SVG to the obtuse marginal branch utilizing a 0.010 inch high torque floppy guidewire (Advanced Cardiovascular Systems) and a “TEN” 2 mm balloon catheter (ACS) were unsuccessful. Shortly thereafter, a mobile thrombus, which moved spontaneously in a retrograde manner towards the proximal anastomosis of the SVG with the ascending aorta, was observed under fluoroscopy. Multiple injections of contrast (Hexabrix-Mallinkrodt Pharmaceuticals) into the vein graft did not slow the course of this spontaneous retrograde movement. Due to concern that this thrombus would migrate into the ascending aorta and embolize systemically, the Judkins right 4 guiding catheter was deeply intubated into the saphenous vein graft and a 60 cc Luerlock syringe was connected directly to the guiding catheter. The syringe was continuously aspirated for 2 minutes and approximately 20 cc of blood were removed. Gross and microscopic pathologic anal-
Fig. 2. Mobile thrombus (double arrowhead) in SVG to grafted OM branch.
ysis of the blood aspirate demonstrated white to tan thrombus fragments. Fluoroscopy immediately following the aspiration procedure show a total absence of the mobile filling defect. Balloon angioplasty of the occluded SVG to the obtuse marginal branch was ultimately accomplished utilizing an 8F Amplatz right I guiding catheter (USCI) and 2 mm and 3 mm ACX balloon catheters, along with a 0.014 inch high torque floppy guidewire (ACS). At the conclusion of the procedure, prompt flow had been established through the vein graft into the obtuse marginal branch (Fig. 3). Competitive flow was absent in the marginal branch, and there was no evidence of distal embolization. The patient returned to the CCU. Clinical follow-up demonstrated no neurologic sequela or rise in CPK. She was maintained on systemic heparinization for 2 days and discharged home angina free and in stable conduction.
DISCUSSION
Percutaneous aspiration of thrombotic debris has been employed in the peripheral arterial circulation [ 11 as well as in the coronary circulation [2]. Percutaneous aspiration of thrombotic debris from a saphenous vein graft has also been described previously [3,4]. In the latter 2 reports, saphenous vein graft aspiration was performed in the setting of an acute myocardial infarction and ongoing
Mobile Thromboembolus Aspiration
51
and retrograde eddys, which produced the spontaneous motion of thrombotic debris in a retrograde direction. The present case illustrates a novel solution to an unusual situation. Potential benefits of such a procedure need to be weighed against risks in a case by case manner. The deep seating of a guiding catheter into a saphenous vein conduit is not without hazard and has the potential to result in dissection or occlusion. Nevertheless, in certain circumstances cautious application of percutaneous aspiration of thrombotic debris from segments of saphenous vein grafts appears to be an alternative therapeutic approach worthy of consideration. ACKNOWLEDGMENTS
We are grateful for the technical support and assistance of Mr. Jonas Juska and the Cardiac Catheterization team at St. Joseph Hospital and Health Care Center in Chicago. We also gratefully acknowledge the help of Ms. Equilla Larme in the preparation of this manuscript. Fig. 3. Angiographic appearance of the saphenous vein graft to the obtuse marginal branch following thrombus aspiration and successful PTCA.
instability. In neither report was there evidence that the thrombus was mobile or moved spontaneously. The spontaneous migration of thrombus described in this case may be related to the absence of distal antegrade flow in a tubular conduit. The occluded vein graft created a “blind pouch” in which blood flow from the ascending aorta may have established countercurrents
REFERENCES Dorros G, Jamnadas P, Lewin RF, Sachdev N: Percutaneous aspiration of a thromboembolus. Cathet Cardiovasc Diagn 17:202206, 1989. Leblanche JM, Fourreier JL, Gommeaux A, Becquarf J , Bertrand ME: Percutaneous aspiration of a coronary thrombus. Cathet Cardiovasc Diagn 17:97-98, 1989. Feldman RC: Transcatheter aspiration of a thrombus in an aortocoronary saphenous vein graft. Am J Cardiol 60:379-380, 1987. Kahn JK, Hartzler Go: Thrombus aspiration in acute myocardial infarction. Cathet Cardiovasc Diagn 20:54-57, 1990.
Aspiration of a Mobile Thromboembolus From Saphenous Vein Graft Harry M. Cohen, MD, FACC, and Jay H. Kleiman, MD, FACC An 81-year-old woman who was 4 years post Svessel coronary artery bypass graft (CABG) surgery suffered a non-Q-wave myocardial infarction. Angiography revealed the recent occlusion of a saphenous vein graft (SVG) to an obtuse marginal coronary artery. Five days following failure of intragraft urokinase and systemic heparinization to recanalize the SVG, balloon angioplasty was undertaken. A mobile thrombus was observed to migrate spontaneouslyin a retrograde manner in the SVG and was removed during PTCA by aspiration through the guiding catheter. o 1992 wiiey-~iss,inc. Key words: non-Q MI, saphenous vein bypass graft, intragraft urokinase, percutaneous aspiration of mobile thrombus, PTCA of occluded SVG
INTRODl CTlO
a 90% ostial right coronary narrowing, and a critical mid right coronary artery lesion were demonstrated. The saThe definitive transcatheter therapeutic modality for phenous vein bypass graft (SVG) to the right coronary effectively dealing with thrombus in a native coronary artery was occluded at its origin. The SVG to the obtuse artery or saphenous vein bypass graft (SVG) has yet to be marginal was also occluded with filling defects in its defined. Numerous mechanical modalities (balloon anproximal portion compatible with thrombus. The SVG to gioplasty , atherectomy, and intracoronary laser applicathe LAD coronary artery was still widely patent and tions), as well as pharrnacologic interventions (systemic filled the distal LAD, which in turn collateralized the heparinization, thrombolytic therapy), both alone and in previously grafted obtuse marginal branch of the left circombination, have been tried with variable success. Litcumflex coronary system. Left ventricular function tle has been reported in the literature, however, about showed moderate global impairment. At the time of corstrategies to deal with a mobile thrombus, whether in a onary angiography, 10,OOOU heparin were given intranative coronary artery or in a saphenous vein bypass venously and 500,000 U urokinase were infused through graft. We report a technique utilized to deal with a moa diagnostic coronary catheter directly into the occluded bile thrombus that was observed to migrate spontaneSVG to the obtuse marginal branch. Immediately followously in a retrograde manner in a saphenous vein bypass ing this selective urokinase infusion, a modest decrease graft. in the extent of filling defects was noted in the proximal vein graft. No antegrade flow beyond the point of occlusion was established. CASE REPORT The patient was brought back to the cardiac catheterization laboratory 5 days following her first angiographic An 81-year-old white female underwent coronary arprocedure due to refractory anginal pain in spite of contery bypass graft surgery (CABG) in 1987 with 3 sepatinued treatment with intravenous heparin and nitroglycrate saphenous vein bypass grafts placed to her LAD, left erine. Repeat angiography was essentially unchanged. circumflex, and right coronary arteries. The patient reSVG to the LAD again demonstrated Angiography of the mained angina free until July 1991. In September 1991 she was hospitalized with recurrent anginal chest pain and sustained a non-Q wave myocardial infarction. She was stabilized with intravenous heparin and nitroglycer- From the St. Joseph Hospital and Medical Center and Northwestern ine, aspirin, and procardia. The patient underwent car- University Medical School, Chicago, Illinois. diac catheterization on the second day of her hospitalReceived December 7, 1991; revision accepted April 7, 1992. ization. Coronary angiography revealed a 90 percent left main Address Reprint Requests to Harry M. Cohen, M.D.,Northside Carlesion with an adjacent 95% ostial left circumflex coro- diology Group, Ltd., 2800 North Sheridan Road, Suite 606,Chicago, nary artery stenosis. A 100% occlusion of the mid LAD, IL 60657. 0 1992 Wiley-Liss, Inc.
50
Cohen and Kleiman
Fig. 1. Angiographic appearance of the occluded saphenous vein graft to the obtuse marginal branch in an 81-yearold woman 7 days following an acute non-Q wave MI. Five days earlier, urokinase had been selectively infused into the graft. Note the filling defect consistent with thrombus. This was later observed to migrate spontaneously (double arrowhead). Residual thrombus that remained stable without migration is present prior to the point of total occlusion (single arrowhead).
collateral flow to the obtuse marginal branch of the circumflex coronary artery from the distal LAD. It was felt that the patient’s continuing refractory anginal pain was due to the inadequacy of this collateral flow and that recannulization of the recently occluded SVG to this marginal coronary branch would likely reverse her recurring clinical ischemia. Initial attempts to recannulize the occluded SVG to the obtuse marginal branch utilizing a 0.010 inch high torque floppy guidewire (Advanced Cardiovascular Systems) and a “TEN” 2 mm balloon catheter (ACS) were unsuccessful. Shortly thereafter, a mobile thrombus, which moved spontaneously in a retrograde manner towards the proximal anastomosis of the SVG with the ascending aorta, was observed under fluoroscopy. Multiple injections of contrast (Hexabrix-Mallinkrodt Pharmaceuticals) into the vein graft did not slow the course of this spontaneous retrograde movement. Due to concern that this thrombus would migrate into the ascending aorta and embolize systemically, the Judkins right 4 guiding catheter was deeply intubated into the saphenous vein graft and a 60 cc Luerlock syringe was connected directly to the guiding catheter. The syringe was continuously aspirated for 2 minutes and approximately 20 cc of blood were removed. Gross and microscopic pathologic anal-
Fig. 2. Mobile thrombus (double arrowhead) in SVG to grafted OM branch.
ysis of the blood aspirate demonstrated white to tan thrombus fragments. Fluoroscopy immediately following the aspiration procedure show a total absence of the mobile filling defect. Balloon angioplasty of the occluded SVG to the obtuse marginal branch was ultimately accomplished utilizing an 8F Amplatz right I guiding catheter (USCI) and 2 mm and 3 mm ACX balloon catheters, along with a 0.014 inch high torque floppy guidewire (ACS). At the conclusion of the procedure, prompt flow had been established through the vein graft into the obtuse marginal branch (Fig. 3). Competitive flow was absent in the marginal branch, and there was no evidence of distal embolization. The patient returned to the CCU. Clinical follow-up demonstrated no neurologic sequela or rise in CPK. She was maintained on systemic heparinization for 2 days and discharged home angina free and in stable conduction.
DISCUSSION
Percutaneous aspiration of thrombotic debris has been employed in the peripheral arterial circulation [ 11 as well as in the coronary circulation [2]. Percutaneous aspiration of thrombotic debris from a saphenous vein graft has also been described previously [3,4]. In the latter 2 reports, saphenous vein graft aspiration was performed in the setting of an acute myocardial infarction and ongoing
Mobile Thromboembolus Aspiration
51
and retrograde eddys, which produced the spontaneous motion of thrombotic debris in a retrograde direction. The present case illustrates a novel solution to an unusual situation. Potential benefits of such a procedure need to be weighed against risks in a case by case manner. The deep seating of a guiding catheter into a saphenous vein conduit is not without hazard and has the potential to result in dissection or occlusion. Nevertheless, in certain circumstances cautious application of percutaneous aspiration of thrombotic debris from segments of saphenous vein grafts appears to be an alternative therapeutic approach worthy of consideration. ACKNOWLEDGMENTS
We are grateful for the technical support and assistance of Mr. Jonas Juska and the Cardiac Catheterization team at St. Joseph Hospital and Health Care Center in Chicago. We also gratefully acknowledge the help of Ms. Equilla Larme in the preparation of this manuscript. Fig. 3. Angiographic appearance of the saphenous vein graft to the obtuse marginal branch following thrombus aspiration and successful PTCA.
instability. In neither report was there evidence that the thrombus was mobile or moved spontaneously. The spontaneous migration of thrombus described in this case may be related to the absence of distal antegrade flow in a tubular conduit. The occluded vein graft created a “blind pouch” in which blood flow from the ascending aorta may have established countercurrents
REFERENCES Dorros G, Jamnadas P, Lewin RF, Sachdev N: Percutaneous aspiration of a thromboembolus. Cathet Cardiovasc Diagn 17:202206, 1989. Leblanche JM, Fourreier JL, Gommeaux A, Becquarf J , Bertrand ME: Percutaneous aspiration of a coronary thrombus. Cathet Cardiovasc Diagn 17:97-98, 1989. Feldman RC: Transcatheter aspiration of a thrombus in an aortocoronary saphenous vein graft. Am J Cardiol 60:379-380, 1987. Kahn JK, Hartzler Go: Thrombus aspiration in acute myocardial infarction. Cathet Cardiovasc Diagn 20:54-57, 1990.
