Management of intracoronary thrombus in 2002

Safety and efficacy of intense antithrombotic treatment and percutaneous coronary intervention deferral in patients with large intracoronary thrombus

The optimal management of a large intracoronary thrombus in patients with acute coronary syndromes without an urgent need of revascularization is unclear. We investigated whether deferring percutaneous coronary intervention (PCI) after a course of intensive antithrombotic therapy (ATT) (glycoprotein IIb/IIIa inhibitors, enoxaparin, aspirin, and clopidogrel) improves the outcomes compared with immediate PCI. We studied 133 stable patients with ACS and a large intracoronary thrombus and without an urgent need for revascularization at angiography. The angiographic and in-hospital outcomes of a prospective cohort of 89 patients who had undergone deferred angiography with or without PCI after ATT (d-PCI) were compared with a historical cohort of 44 patients who had undergone immediate PCI, matched for age, gender, and Thrombolysis In Myocardial Infarction thrombus grade. The absolute thrombus volume was measured before and after ATT using dual quantitative coronary angiography. All d-PCI patients remained stable during ATT (60.0 ± 30.8 hours). A significant reduction in the Thrombolysis In Myocardial Infarction thrombus grade (4, range 4 to 5, vs 3, range 2 to 4; p <0.001), thrombus volume (51.1, range 32.1 to 83, vs 38.1, range 21.7 to 50.7 mm(3); p <0.001), stenosis severity (73.8 ± 25.8% vs 60.3 ± 32.5%; p <0.001) and better Thrombolysis In Myocardial Infarction flow (2, range 0 to 3, vs 3, 1.5 to 3; p <0.001) were noted after ATT. PCI, stenting, and thrombus aspiration were performed less frequently in the d-PCI group (76.4% vs 100%, p <0.001; 70.8% vs 93.2%, p = 0.003; and 21% vs 100%, p <0.001, respectively). However, distal embolization and slow and/or no-reflow were more common during immediate PCI (31.8% vs 9%; p = 0.001). No life-threatening or severe hemorrhagic complications were observed, although the rate of mild and/or moderate bleeding was similar between the 2 groups (6.8% in immediate PCI vs 7.9% in d-PCI; p = 0.829). In conclusion, compared with immediate PCI, d-PCI after ATT in selected, stabilized patients with ACS and a large intracoronary thrombus and without an urgent need for revascularization is probably safe and associated with a reduction in thrombotic burden, angiographic complications, and the need of revascularization. These benefits were observed without an increase in hemorrhagic complications.

Late or very late stent thrombosis can also occur with bare metal stents

The issue of late stent thrombosis (LAST) has become a subject of highly polemical debate over the past few months. Yet, both acute and LAST has always been a potential complication. The objective of this manuscript is to remind the readers, by means of two case reports, that thrombosis of bare metal stents may occur even very late after stent implantation. In the first case, stent thrombosis occurred after five years. In the second case, it occurred three years after the stenting procedure in a bare metal stent implanted in the circumflex artery of a patient who had also received two drug-eluting stents in the left anterior descending coronary artery.