MINM

Mr. MINM, a 66 years old gentleman who has underlying poorly controlled diabetes on insulin presented to our center with typical angina symptoms 4 hours prior to the admission. His ECG on arrival to emergency department showed ST elevation over V3-V6 leads and II, III, aVF leads with ST depression over I, aVL leads. His vital signs were stable and physical examinations were unremarkable. He then treated as acute extensive anterior myocardial infarction and pushed for primary PCI.

Normal full blood countKidney profile showed CKD stage 4 with urea of 15/ crea 325 eGFR 17, potassium was 5.8Blood sugar was 20 on arrival. Mild metabolic acidosis noted on blood gas.Troponin T was highly elevated >10,000 pg/ml

Coronary angiogram showed:Left Main Stem : Normal Left Anterior Descending (LAD) : Diffuse disease in LAD , severe (subtotal) stenosis of mid Left Anterior Descending , severe disease in distal LAD. Left Circumflex Artery(LCX) : Diffuse mild disease. Right Coronary Artery(RCA) : Acute total occlusion in proximal RCA with heavy thrombus, retrograde flow into Right Posterior Descending Artery from left coronaries.
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We decided for primary PCIof RCA. Wired across the lesion and thrombus catheter was introduced but was unableto cross the lesion proximally. We predilated the proximal with MINITREK 2.0x15mm balloon. Initial aspiration done with thrombus II noted multiple ofblood clots. We predilated the vessel further with TREK 2.5/15mm balloon.Thrombus II aspiration done again, still noted heavy thrombus in the proximal anddistal RCA. Our strategy then was to give intracoronary glycoprotein (GP) IIb/IIIa antagonists and try to suction the large thrombus with Penumbra. However,there was still heavy thrombus burden with poor distal run off and wedecided to stop further intervention. Our plan then was to continue IV GP IIb/IIIa antagonists foranother 12hours with a repeat coronary angiogram 72 hours later. He received lowmolecular weight heparin and standard dual antiplatelets medications. Unfortunately, his repeat coronary angiogram later still show large thrombus burden despite multiple times of aspiration. Intravascular ultrasound done showed heavy thrombus burden from proximal to mid segment with vessel size proximal5.0mm-5.5mm, distal 3.0mm.We were able to establishflow distally after the aspiration however still noted heavy thrombus inside the coronary. We thendecided to stop the procedure. He received anticoagulant with single antiplatelet with a plan to restudy back in 3 months-time.
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This is a case of high thrombus burden in rightcoronary artery who came with acute myocardial infarction. We practiced intracoronary thrombus aspiration with export  and Penumbra catheter together with intracoronary intracoronary glycoprotein (GP) IIb/IIIa antagonists, despite all his thrombus remain high. As implanted coronary stents in a large thrombus burden coronary artery may be associated with distal embolization, impaired flow with an increased risks of peri-procedural complications, our strategies are to defer the coronary stenting and started him on anticoagulant with antiplatelet medications and restudy back later with the aim of resolution or reduction of the heavy thrombus.