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Controversies in Primary Angioplasty

Delay PCI strategy in thrombus laden STEMI
Does Intense Anti-coagulation Therapy for Those with Unsatisfactory
Thrombectomy work?

Dr Michael Liang, MBChB, FRACP, FAMS, FACC
Department of Cardiology, Khoo Teck Puat Hospital Singapore.


Disclosure/Conflict of Interests

NONE


Introduction
• Thrombus Laden coronary artery occurred frequently in primary
angioplasty setting.
• Increasing “burden of thrombus” predicts the following:
–
–
–
–

(1) Longer procedure time with larger amount of thrombi
(2) Imminent risk of flow impairment
(3) Distal embolization
(4) No flow phenomenon with micro-circular obstruction and infarct
expansion
– (5) In treated inadequately, it may results in arrhythmia, cardiogenic shock
or even death.

Mehta S. Clinics of America Sep 2009


51 yo man, Inferior STEMI with Complete heart
block and Cardiogenic shock


Distal RCA – Culprit lesion


Straightforward PCI with aspiration catheter

3.5x26 mm DES

Procedure Time 25 mins.


42 yo, Male, Inferior STEMI. Grade 4 Thrombus
• 6 Fr right radial approach
• LCA – normal
• RCA 
• Went into complete heart
block.
• Temporary pacing wire
was inserted


“Beat the clot with balloon and aspiration catheter”

Eliminate 6 Fr Aspiration Catheter
Terumo

2.0x20 mm compliant balloon


“Getting worse”

4Fr Angiojet


• Procedure Time 1hr 58
minutes.
• Antiplatelet
– Aspirin/Clopidogrel

• 1 days IV Integrilin
(Eptifibatide)
• 5 days s/c Enoxaparin


Index procedure

1 week later with Anti-coagulation


Intense Anti-coagulation Therapy for Those with
Unsatisfactory Thrombectomy in STEMI
• Index Procedure: achieve best flow possible with thrombectomy or

balloon dilatation.
• IIbIIIa inhibitor infusion for at least 24 hours followed by
Enoxaparin treatment dose.
– Sometimes both IIb/IIIa inhibitor and enoxaparin can be used together,
especially in younger patient with lower bleeding risk.

• Dual antiplatelet – aspirin/Ticagrelor or Clopidogrel
• Repeat angiography and consider PCI if appropriate.
– At least after 72hours of anti-coagulation


51yr M, Inferior STEMI, 6 hours after pain onset
• Grade 5 Thrombus
– Total occlusion
– No angiojet available

Occluded proximal RCA


Unsatisfactory Result  Intense anti-coagulation
• Aspirate and dilate with
3x15 mm compliant
balloon
• Procedure Time 1:07min
• 24 hour Integrilin Infusion
• 5 days of Enoxaparin S/C
bd


1 week later

5x24 mm Liberte


46 yr old lady with lateral STEMI

Grade 4 Thrombus at ostial left circumflex
artery and the first obtuse marginal branch
(Filling defect >2x vessel diameter)

Post-Thrombectomy Final Results
Procedure time: 34 mins


• After 3 Days Enoxaparin
1mg/kg S/C BD
• FFR to LAD - 0.86
• FFR to OM1 – 0.80
• Medical therapy
• > 1year follow-up
– Asymptomatic


65yo man with Inferior STEMI
• Resolution of chest pain
in lab.
• Grade 4 thrombotic
burden
• Aspirin and clopidogrel
• IV Integrilin infusion x

24hours
• Enoxaparin 1mg/kg S/C 6
days


1 week later
• Proximal RCA thrombus
almost completely
resolved
• Residual thrombus in
distal RCA with a tight
distal lesion

• Proceed to PCI


3x30 mm Drug-Eluting Balloon
Wires both PDA/RPL
50 seconds
Aspiration Catheter
and 3.0 x15 mm
2x15 mm balloon to gently disrupt
balloon to dilate the vessel Same 3x30 mm Drug-Eluting Balloon
thrombus
30 seconds


Our Experience with Intense Anti-coagulation
Therapy in Grade 4 and 5 Thrombus Burden
No.

11

Male

90.9%

Mean age (years), age + SD

53 + 9

Coronary Artery Involved
Left main

0

Left anterior descending artery

1 (9.1%)

Left circumflex artery

1 (9.1%)

Right coronary artery

9 (81.8%)

Median Anti-coagulation, days

7 (range 4-7)

Anti-coagulation

24 hours of IV Integrilin infusion followed by
treatment dose of Enoxaparin

Significant bleeding

0

Stenting /DEB required at relook procedure

4 (36.3%)
Sekar et al. AICT 2016


Change in culprit vessel TIMI 3 flow following
intense anti-coagulation

TIMI 3

TIMI 3

TIMI Flow
3
2
1

Conclusion – Learning Points
• The “delayed-PCI or staged strategy” following Intense
anticoagulation therapy in culprit vessel with large thrombusburden is beneficial and safe in those patients with unsatisfactory
thrombectomy during the index procedure.
• Optimum anti-coagulation regime and duration is unknown.
• Glycoprotein IIb/IIIa inhibitor infusion followed by Enoxaparin is
recommended for at least 72 hours before restudy the coronary
angiography.