Slides

Intracoronary thrombolysis in the lesion with massive thrombus

Treatment for lesion with heavy thrombus was still very challenging situation. No-reflow phenomenon and impaired myocardial perfusion resulting from distal embolism frequently occurred. Recently, it was reported that thrombus aspiration in the setting of primary PCI for STEMI led to better myocardial perfusion. A total of 1071 patient were randomly assigned to the thrombus-aspiration group or conventional-PCI group. Poor myocardial perfusion defined as myocardial blush grade of 0 or 1 (primary outcome) was more common in conventional-PCI group (17.1% vs. 26.3%, p<0.001) and complete resolution of ST segment elevation was more frequently observed in thrombus-aspiration group (56.6% vs. 44.2%, p<0.001).1

Another attempt was a pharmacologic approach using intracoronary infusion of thrombolytic agent. Cortese B. et al treated 12 AMI patients with large intracoronary thrombus burden using intracoronary thrombolysis on the top of intracoronary GpIIb/IIIa inhibitor. They observed the reduction of final thrombus burden without increasing the risk of bleeding.2 Ishibashi F et al. retrospectively analyzed 80 AMI patients : 40 undergoing primary PTCA alone and 40 treated with preceding intracoronary thrombolysis plus PTCA. TIMI 0/1 flow was more frequent in PTCA alone group (35% vs. 12.5%, p=0.06).3 Sezer M et al. evaluated the effect of low-dose intracoronary streptokinase (250kU) administered immediately after primary PCI, which was associated with improved post procedural myocardial reperfusion assessed by coronary flow reserve, the index of microvascular resistance, and collateral flow index4 and better global LV function and size at 6 months.5
REFERENCES
1.Svilaas T, Vlaar PJ, van der Horst IC, et al. Thrombus aspiration during primary percutaneous coronary intervention. N Engl J Med 2008;358:557-67.
2.Cortese B, Micheli A, Picchi A, Limbruno U. Combined, superselective pharmacological management of large coronary thrombus burden. J Invasive Cardiol 2009;21:168-71.
3.Ishibashi F, Saito T, Hokimoto S, Noda K, Moriyama Y, Oshima S. Combined revascularization strategy for acute myocardial infarction in patients with intracoronary thrombus: preceding intracoronary thrombolysis and subsequent mechanical angioplasty. Jpn Circ J. 2001;65:251-6.
4.Sezer M, Oflaz H, Goren T, Okcular I, Umman B, Nisanci Y, Bilge AK, Sanli Y, Meric M, Umman S. Intracoronary streptokinase after primary percutaneous coronary intervention. N Engl J Med. 2007;356:1823-34.
5.Sezer M, Cimen A, Aslanger E, Elitok A, Umman B, Bugra Z, Yormaz E, Turkmen C, Adalet IS, Nisanci Y, Umman S. Effect of intracoronary streptokinase administered immediately after primary percutaneous coronary intervention on long-term left ventricular infarct size, volumes, and function. J Am Coll Cardiol. 2009 15;54:1065-71.

Comments

  • shafique 2010-09-27 it is a very challenging topic for persons involved in primary PCI and rescue PCI. i think it is good preview but we need more evidence to draw a proper recommendation.

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