Cardiovascular Revascularization Medicine 14 (2013) 356–358
Contents lists available at ScienceDirect
Cardiovascular Revascularization Medicine
Case Reports
Guiding-catheter thrombectomy combined with distal protection during primary percutaneous coronary intervention of a saphenous vein graft☆ Julio García-Tejada, Alfonso Jurado-Román ⁎, Felipe Hernández, Roberto Martín Asenjo, Javier Molina Martín de Nicolás, Agustín Albarrán, Maite Velázquez, Juan Tascón Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
a r t i c l e
i n f o
Article history: Received 24 February 2013 Received in revised form 9 April 2013 Accepted 11 April 2013 Keywords: Percutaneous intervention Saphenous vein graft Thrombectomy Distal protection Myocardial infarction
a b s t r a c t Primary percutaneous intervention of saphenous vein grafts is associated with a high risk of distal embolization and no reflow. We report a case of acute myocardial infarction with a large intragraft thrombus, successfully treated with a technique combining thrombectomy with a 6 Fr guiding catheter and distal protection with the FilterWire EZ. © 2013 Elsevier Inc. All rights reserved.
1. Introduction Primary percutaneous coronary intervention (PCI) of saphenous vein graft (SVG) lesions with a large thrombus load is associated with a high risk of distal embolization and no-reflow [1,2]. Therefore, in deciding on the best protection strategy, it is important to consider specific lesion and vessel characteristics, as well as thrombus burden. We report a case of acute myocardial infarction (AMI) in which emergent angiography demonstrated a large thrombus in a SVG. The combination of manual thrombosuction with the guiding catheter and distal protection with the filterWire EZ resulted in immediate resolution of chest pain, electrocardiographic changes and normalization of TIMI flow. 2. Case report A 48-year-old man presented to the emergency department 2 h after onset of severe chest pain. He had a past medical history of coronary artery bypass graft surgery 7 years before, with left internal mammary artery (LIMA) to the left anterior descending artery (LAD), and saphenous vein grafts (SVG) to an obtuse marginal branch and to the right posterior descending artery (RPDA). Since the ST segment was elevated in leads II, III and aVF, a diagnosis of inferior AMI was made. The patient was premedicated with aspirin, clopidogrel,
☆ All the authors declare to have NO conflict of interest. ⁎ Corresponding author. Hospital Universitario 12 de Octubre. Avenida de Córdoba s/n 28041. Madrid, Spain. Tel.: +34 629871863. E-mail address: [email protected] (A. Jurado-Román). 1553-8389/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.carrev.2013.04.004
intravenous unfractionated heparin and abciximab, and transferred for emergent angiography. Angiography showed a patent LIMA graft to the LAD. The native LAD was totally occluded after the first diagonal branch. The native left circumflex had a 70% proximal stenosis, and a SVG to the first marginal branch was patent. The native RCA was totally occluded. The culprit lesion was identified in the SVG to the RPDA, which presented a large filling defect in its mid portion and TIMI-II flow (Fig. 1A). The SVG was engaged with a soft-tip multipurpose guiding catheter (Cordis) and initially wired with a 0.014” Hi-torque Balance Middleweight guidewire (Guidant). Since the catheter fit well and aligned straight in the graft, it was slowly advanced over the wire to the distal portion of the graft (Fig. 1B). The wire was then removed and, mantaining constant negative suction, the guiding catheter was slowly withdrawn from the SVG and out of the femoral sheath. Flushing the guiding catheter revealed a large thrombus that matched the filling defect (Fig. 2). This thrombosuction resulted in immediate resolution of chest pain and electrocardiographic changes. The guiding catheter was reinserted and angiography revealed a patent graft with TIMI-III flow, and evidence of very small filling defects suggestive of residual thrombotic material (Fig. 3A; arrows). Due to concerns about the development of no-reflow we recrossed the lesion using a FilterWire EZ (Boston Scientific) before stenting (Fig. 3B; arrow). A 4 × 20 mm Taxus-Liberte stent (Boston Scientific) was then implanted to treat the index lesion. Following stent deployment, angiography revealed full stent expansion, no residual stenosis, but slow-flow in the graft suggesting distal embolization of the residual thrombotic material. The filterWire EZ was then removed and final angiography showed a successful angiographic result and TIMI-III flow into the distal SVG-RPDA (Fig. 4). Visual inspection of the
J. García-Tejada et al. / Cardiovascular Revascularization Medicine 14 (2013) 356–358
Fig. 1. A. Left anterior oblique 35º projection. Angiography revealed a large filling defect in the mid portion of the saphenous vein graft to the right posterior descending artery (RPDA). B. The guiding catheter was slowly advanced across the lesion to the distal portion of the graft while a steady negative pressure was maintained.
retrieved filter revealed few small pieces of thrombus. The patient had an uneventful post-procedural course and is free of symptoms after 2 years of follow-up.
3. Discussion Patients who present with AMI due to SVG occlusion offer a difficult therapeutic challenge. Due to the large vessel size and the large thrombus load in the culprit lesion, primary PCI of SVG is frequently complicated by distal embolization and no-reflow [1]. Therefore, procedural and short-term clinical outcomes are much worse than for primary PCI of occluded native vessels. In deciding on the best
Fig. 2. A large thrombus was aspirated from the graft with the guiding catheter and small debris were captured with the FilterWire EZ. Note that the diameter of the ovalshaped loop that supports the porous membrane filter is 5 mm.
357
Fig. 3. A. Angiography following guiding catheter aspiration showed a marked improvement in angiographic appearance and evidence of small residual thrombotic material (arrows). B. Angiography following stent deployment showed slow-flow in the graft. See the radiopaque loop of the FilterWire EZ positioned in the distal portion of the graft (arrow).
protection strategy, it is important to consider specific lesion and vessel characteristics, as well as thrombus burden. Guiding-catheter thrombectomy has been previously reported to be effective in AMI patients with a large thrombus load [2,3]. In our case, the potential of guiding catheter thrombectomy was clearly demonstrated by the amount of aspirated thrombus, the improvement of coronary flow and the clinical outcome. It is unlikely that any other device, like a conventional thrombectomy catheter, would have debulked such a
Fig. 4. Final angiographic result after retrieval of the filter showed no residual stenosis and complete filling of the graft and of the RPDA distally.
358
J. García-Tejada et al. / Cardiovascular Revascularization Medicine 14 (2013) 356–358
large amount of thrombotic material and achieved a similar result so promptly. This may be because the cross-sectional area of the 6 Fr catheter is 2.5 mm [1], while that of other more technologically sophisticated devices is too small for effective thrombosuction in a vessel with a large thrombus load. This case demonstrates that with a suitable anatomy, particularly if no tortuosity or diffuse disease exists, a guiding catheter can be advanced to the distal segments of a SVG, thus allowing successful aspiration of thrombotic material. Potential risks of guiding catheter aspiration include catheter-induced trauma and systemic embolization [3]. In our case, the catheter was aligned almost straight on the graft, so the massive thrombus could be extracted without major injury to the vessel wall. The use of a soft-tip guiding catheter and its cautious advancement over the wire could also prevent the occurrence of catheter-induced trauma or dissection of the vessel. In addition, maintaining continuous negative suction on the syringe while withdrawing the guiding catheter out of the sheath minimized the risk of systemic embolization, and allowed that the aspired material could be obtained for further examination. As it has been described, we decided to remove de guidewire to facilitate the thrombus aspiration during extraction of the guiding-catheter while producing negative suction and to prevent distal embolization. Furthermore, due to the characteristics of the vessel and the lesion, rapid reinsertion of the guiding-catheter and recrossing with the guidewire did not pose any difficulties [3]. In our patient, although thrombosuction with the guiding catheter extracted a massive intragraft thrombus, the posterior angiography showed the presence of a small residual thrombus, and due to concerns about the development of no-reflow, we decided to use a distal protection device (FilterWire EZ) before stenting. Trials of routine use of embolic protection devices for primary PCI have demonstrated neutral or negative effects of these devices on myocardial reperfusion and final infarct size [4,5]. However, the safety and the feasibility of the FilterWire in AMI have been previously
reported in selected patients [6]. Moreover, distal protection devices are considered the standard of care in the setting of PCI for SVG, even in the absence of angiographically visible thrombus [7]. In our patient, angiography revealed slow-flow in the graft after stenting, suggesting distal embolization of the residual thrombotic material. Moreover, antegrade flow returned to normal with removal of the filter, and visual inspection of the retrieved filter confirmed the presence of small visible debris. The capability of the FilterWire EZ to capture emboli has been demonstrated in the present report. Since the filters may become full, and may spill their contents when collapsed during retrieval, our aspirate-first approach was very useful to minimize thrombus burden and avoid this potential complication.
References [1] Nguyen TT, O’Neill WW, Grines CL, Stone GW, Brodie BR, Cox DA, et al. One-year survival in patients with acute myocardial infarction and a saphenous vein graft culprit treated with primary angioplasty. Am J Cardiol 2003;91:1250–4. [2] Dooris M, Grines CL. Successful reversal of cardiogenic shock precipitated by saphenous vein graft distal embolization using aspiration thrombectomy. Cathet Cardiovasc Diagn 1994;33:267–71. [3] Moscucci M, Punamiya K, Ricciardi MJ. Guiding catheter thrombectomy during percutaneous coronary interventions for acute coronary syndromes. Cathet Cardiovasc Interv 2000;49:192–6. [4] Stone GW, Webb J, Cox DA, Brodie BR, Qureshi M, Kalynych A, et al. Distal microcirculatory protection during percutaneous coronary intervention in acute ST-segment elevation myocardial infarction: a randomized controlled trial. JAMA 2005;293:1063–72. [5] Gick M, Jander N, Bestehorn H, Kienzle RP, Ferenc M, Werner K, et al. Randomized evaluation of the effects of filter-based distal protection on myocardial perfusion and infarct size after primary percutaneous catheter intervention in myocardial infarction with and without ST-segment elevation. Circulation 2005;112:1462–9. [6] Limbruno U, Micheli A, De Carlo M, Amoroso G, Rossini R, Palagi C, et al. Mechanical prevention of distal embolization during primary angioplasty: safety, feasibility, and impact on myocardial reperfusion. Circulation 2003;108:171–6. [7] Baim DS, Wahr D, George B, Leon MB, Greenberg J, Cutlip DE, et al. Randomized trial of a distal embolic protection device during percutaneous intervention of saphenous vein aorto-coronary bypass grafts. Circulation 2002;105:1285–90.
Contents lists available at ScienceDirect
Cardiovascular Revascularization Medicine
Case Reports
Guiding-catheter thrombectomy combined with distal protection during primary percutaneous coronary intervention of a saphenous vein graft☆ Julio García-Tejada, Alfonso Jurado-Román ⁎, Felipe Hernández, Roberto Martín Asenjo, Javier Molina Martín de Nicolás, Agustín Albarrán, Maite Velázquez, Juan Tascón Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
a r t i c l e
i n f o
Article history: Received 24 February 2013 Received in revised form 9 April 2013 Accepted 11 April 2013 Keywords: Percutaneous intervention Saphenous vein graft Thrombectomy Distal protection Myocardial infarction
a b s t r a c t Primary percutaneous intervention of saphenous vein grafts is associated with a high risk of distal embolization and no reflow. We report a case of acute myocardial infarction with a large intragraft thrombus, successfully treated with a technique combining thrombectomy with a 6 Fr guiding catheter and distal protection with the FilterWire EZ. © 2013 Elsevier Inc. All rights reserved.
1. Introduction Primary percutaneous coronary intervention (PCI) of saphenous vein graft (SVG) lesions with a large thrombus load is associated with a high risk of distal embolization and no-reflow [1,2]. Therefore, in deciding on the best protection strategy, it is important to consider specific lesion and vessel characteristics, as well as thrombus burden. We report a case of acute myocardial infarction (AMI) in which emergent angiography demonstrated a large thrombus in a SVG. The combination of manual thrombosuction with the guiding catheter and distal protection with the filterWire EZ resulted in immediate resolution of chest pain, electrocardiographic changes and normalization of TIMI flow. 2. Case report A 48-year-old man presented to the emergency department 2 h after onset of severe chest pain. He had a past medical history of coronary artery bypass graft surgery 7 years before, with left internal mammary artery (LIMA) to the left anterior descending artery (LAD), and saphenous vein grafts (SVG) to an obtuse marginal branch and to the right posterior descending artery (RPDA). Since the ST segment was elevated in leads II, III and aVF, a diagnosis of inferior AMI was made. The patient was premedicated with aspirin, clopidogrel,
☆ All the authors declare to have NO conflict of interest. ⁎ Corresponding author. Hospital Universitario 12 de Octubre. Avenida de Córdoba s/n 28041. Madrid, Spain. Tel.: +34 629871863. E-mail address: [email protected] (A. Jurado-Román). 1553-8389/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.carrev.2013.04.004
intravenous unfractionated heparin and abciximab, and transferred for emergent angiography. Angiography showed a patent LIMA graft to the LAD. The native LAD was totally occluded after the first diagonal branch. The native left circumflex had a 70% proximal stenosis, and a SVG to the first marginal branch was patent. The native RCA was totally occluded. The culprit lesion was identified in the SVG to the RPDA, which presented a large filling defect in its mid portion and TIMI-II flow (Fig. 1A). The SVG was engaged with a soft-tip multipurpose guiding catheter (Cordis) and initially wired with a 0.014” Hi-torque Balance Middleweight guidewire (Guidant). Since the catheter fit well and aligned straight in the graft, it was slowly advanced over the wire to the distal portion of the graft (Fig. 1B). The wire was then removed and, mantaining constant negative suction, the guiding catheter was slowly withdrawn from the SVG and out of the femoral sheath. Flushing the guiding catheter revealed a large thrombus that matched the filling defect (Fig. 2). This thrombosuction resulted in immediate resolution of chest pain and electrocardiographic changes. The guiding catheter was reinserted and angiography revealed a patent graft with TIMI-III flow, and evidence of very small filling defects suggestive of residual thrombotic material (Fig. 3A; arrows). Due to concerns about the development of no-reflow we recrossed the lesion using a FilterWire EZ (Boston Scientific) before stenting (Fig. 3B; arrow). A 4 × 20 mm Taxus-Liberte stent (Boston Scientific) was then implanted to treat the index lesion. Following stent deployment, angiography revealed full stent expansion, no residual stenosis, but slow-flow in the graft suggesting distal embolization of the residual thrombotic material. The filterWire EZ was then removed and final angiography showed a successful angiographic result and TIMI-III flow into the distal SVG-RPDA (Fig. 4). Visual inspection of the
J. García-Tejada et al. / Cardiovascular Revascularization Medicine 14 (2013) 356–358
Fig. 1. A. Left anterior oblique 35º projection. Angiography revealed a large filling defect in the mid portion of the saphenous vein graft to the right posterior descending artery (RPDA). B. The guiding catheter was slowly advanced across the lesion to the distal portion of the graft while a steady negative pressure was maintained.
retrieved filter revealed few small pieces of thrombus. The patient had an uneventful post-procedural course and is free of symptoms after 2 years of follow-up.
3. Discussion Patients who present with AMI due to SVG occlusion offer a difficult therapeutic challenge. Due to the large vessel size and the large thrombus load in the culprit lesion, primary PCI of SVG is frequently complicated by distal embolization and no-reflow [1]. Therefore, procedural and short-term clinical outcomes are much worse than for primary PCI of occluded native vessels. In deciding on the best
Fig. 2. A large thrombus was aspirated from the graft with the guiding catheter and small debris were captured with the FilterWire EZ. Note that the diameter of the ovalshaped loop that supports the porous membrane filter is 5 mm.
357
Fig. 3. A. Angiography following guiding catheter aspiration showed a marked improvement in angiographic appearance and evidence of small residual thrombotic material (arrows). B. Angiography following stent deployment showed slow-flow in the graft. See the radiopaque loop of the FilterWire EZ positioned in the distal portion of the graft (arrow).
protection strategy, it is important to consider specific lesion and vessel characteristics, as well as thrombus burden. Guiding-catheter thrombectomy has been previously reported to be effective in AMI patients with a large thrombus load [2,3]. In our case, the potential of guiding catheter thrombectomy was clearly demonstrated by the amount of aspirated thrombus, the improvement of coronary flow and the clinical outcome. It is unlikely that any other device, like a conventional thrombectomy catheter, would have debulked such a
Fig. 4. Final angiographic result after retrieval of the filter showed no residual stenosis and complete filling of the graft and of the RPDA distally.
358
J. García-Tejada et al. / Cardiovascular Revascularization Medicine 14 (2013) 356–358
large amount of thrombotic material and achieved a similar result so promptly. This may be because the cross-sectional area of the 6 Fr catheter is 2.5 mm [1], while that of other more technologically sophisticated devices is too small for effective thrombosuction in a vessel with a large thrombus load. This case demonstrates that with a suitable anatomy, particularly if no tortuosity or diffuse disease exists, a guiding catheter can be advanced to the distal segments of a SVG, thus allowing successful aspiration of thrombotic material. Potential risks of guiding catheter aspiration include catheter-induced trauma and systemic embolization [3]. In our case, the catheter was aligned almost straight on the graft, so the massive thrombus could be extracted without major injury to the vessel wall. The use of a soft-tip guiding catheter and its cautious advancement over the wire could also prevent the occurrence of catheter-induced trauma or dissection of the vessel. In addition, maintaining continuous negative suction on the syringe while withdrawing the guiding catheter out of the sheath minimized the risk of systemic embolization, and allowed that the aspired material could be obtained for further examination. As it has been described, we decided to remove de guidewire to facilitate the thrombus aspiration during extraction of the guiding-catheter while producing negative suction and to prevent distal embolization. Furthermore, due to the characteristics of the vessel and the lesion, rapid reinsertion of the guiding-catheter and recrossing with the guidewire did not pose any difficulties [3]. In our patient, although thrombosuction with the guiding catheter extracted a massive intragraft thrombus, the posterior angiography showed the presence of a small residual thrombus, and due to concerns about the development of no-reflow, we decided to use a distal protection device (FilterWire EZ) before stenting. Trials of routine use of embolic protection devices for primary PCI have demonstrated neutral or negative effects of these devices on myocardial reperfusion and final infarct size [4,5]. However, the safety and the feasibility of the FilterWire in AMI have been previously
reported in selected patients [6]. Moreover, distal protection devices are considered the standard of care in the setting of PCI for SVG, even in the absence of angiographically visible thrombus [7]. In our patient, angiography revealed slow-flow in the graft after stenting, suggesting distal embolization of the residual thrombotic material. Moreover, antegrade flow returned to normal with removal of the filter, and visual inspection of the retrieved filter confirmed the presence of small visible debris. The capability of the FilterWire EZ to capture emboli has been demonstrated in the present report. Since the filters may become full, and may spill their contents when collapsed during retrieval, our aspirate-first approach was very useful to minimize thrombus burden and avoid this potential complication.
References [1] Nguyen TT, O’Neill WW, Grines CL, Stone GW, Brodie BR, Cox DA, et al. One-year survival in patients with acute myocardial infarction and a saphenous vein graft culprit treated with primary angioplasty. Am J Cardiol 2003;91:1250–4. [2] Dooris M, Grines CL. Successful reversal of cardiogenic shock precipitated by saphenous vein graft distal embolization using aspiration thrombectomy. Cathet Cardiovasc Diagn 1994;33:267–71. [3] Moscucci M, Punamiya K, Ricciardi MJ. Guiding catheter thrombectomy during percutaneous coronary interventions for acute coronary syndromes. Cathet Cardiovasc Interv 2000;49:192–6. [4] Stone GW, Webb J, Cox DA, Brodie BR, Qureshi M, Kalynych A, et al. Distal microcirculatory protection during percutaneous coronary intervention in acute ST-segment elevation myocardial infarction: a randomized controlled trial. JAMA 2005;293:1063–72. [5] Gick M, Jander N, Bestehorn H, Kienzle RP, Ferenc M, Werner K, et al. Randomized evaluation of the effects of filter-based distal protection on myocardial perfusion and infarct size after primary percutaneous catheter intervention in myocardial infarction with and without ST-segment elevation. Circulation 2005;112:1462–9. [6] Limbruno U, Micheli A, De Carlo M, Amoroso G, Rossini R, Palagi C, et al. Mechanical prevention of distal embolization during primary angioplasty: safety, feasibility, and impact on myocardial reperfusion. Circulation 2003;108:171–6. [7] Baim DS, Wahr D, George B, Leon MB, Greenberg J, Cutlip DE, et al. Randomized trial of a distal embolic protection device during percutaneous intervention of saphenous vein aorto-coronary bypass grafts. Circulation 2002;105:1285–90.
![[Instent rupture of a saphenous vein graft during percutaneous intervention successfully treated with a covered stent].](/assets/img/hold.png)
