Extraction of large intracoronary thrombus in acute myocardial infarction by percutaneous Fogarty maneuver: intentional abuse of a novel interventional device

Thrombus in normal coronary arteries: retrospective study and review of case reports

BACKGROUND

Myocardial infarction is rarely caused by non-occlusive thrombus in angiographically normal coronary arteries. The cases reported in the literature are scarce and follow-up was usually short. The efficacy and tolerability of the exclusively medical treatment strategy used in most cases remain unknown.

AIMS

To evaluate efficacy of medical treatment and long-term prognosis in these patients.

METHODS

We retrospectively selected and analysed patients hospitalized in our centre between 1998 and 2008 for myocardial infarction caused by non-occlusive thrombus in angiographically normal coronary arteries (defined as stenosis<30%), who were exclusively medically treated. A long-term follow-up was performed. A review of the literature regarding such cases was carried out.

RESULTS

Sixteen patients were identified; apart from smoking, they had few conventional cardiovascular risk factors. Two patients died in hospital. The 14 survivors were followed up for an average of 4.9 years and only one death (non-cardiac cause) and one stroke (related to supraventricular arrhythmia) occurred in this period. Medical treatment included the use of glycoprotein IIb/IIIa inhibitors in 75% of cases. The literature review revealed 36 similar cases due to multiple aetiologies-particularly coronary artery spasm and prothrombotic coagulopathies.

CONCLUSION

Patients with myocardial infarction secondary to non-occlusive thrombus in angiographically normal coronary arteries seem to have a good long-term prognosis after the acute phase when treated with an exclusively medical strategy. However, initial clinical presentation was often severe, leading to early in-hospital death.

Plaque instability frequently occurs days or weeks before occlusive coronary thrombosis: a pathological thrombectomy study in primary percutaneous coronary intervention

BACKGROUND

Acute ST-elevation myocardial infarction (STEMI) is caused by sudden occlusive coronary thrombosis, after plaque disruption; however, a considerable time interval between plaque disturbance and the onset of symptoms has been suggested. We therefore studied the age of intracoronary thrombi, aspirated during angioplasty in patients with acute STEMI.

METHODS AND RESULTS

Percutaneous intracoronary thrombectomy during angioplasty was performed in 211 consecutive STEMI patients within 6 hours after onset of anginal symptoms. The aspirated material was histologically screened on thrombus and plaque components, and thrombus age was classified as fresh (<1 day), lytic thrombus (1 to 5 days), and organized thrombus (>5 days). In all patients, intracoronary-derived material was retrieved in the filter of the collection bottle. Thrombus was identified in 199 (95%) of 211 patients. In 12 patients (5%), only plaque components were identified, and in 85 patients (41%), both thrombus and plaque material were aspirated. In 18 (9%) of 199 patients, the thrombus was organized, and in 70 patients (35%), the thrombus showed lytic changes, whereas in 98 (49%), a completely fresh thrombus was found. In 14 (7%) of 199 patients, the thrombus showed combined features of both fresh thrombus and organized thrombus.

CONCLUSIONS

In at least 50% of patients with acute STEMI, coronary thrombi were days or weeks old. This indicates that sudden coronary occlusion is often preceded by a variable period of plaque instability and thrombus formation, initiated days or weeks before onset of symptoms.

Three Cases of Acute Myocardial Infarction Due to Coronary Embolism: Treatment Using a Thrombus Aspiration Device

In this report, we describe three patients with acute myocardial infarction due to coronary embolism who were successfully treated using a thrombus aspiration device. Thrombus aspiration is shown to be a feasible and effective strategy for the treatment of acute coronary embolism.