1
|
Noma S, Miyachi H, Fukuizumi I, Matsuda J, Sangen H, Kubota Y, Imori Y, Saiki Y, Hosokawa Y, Tara S, Tokita Y, Akutsu K, Shimizu W, Yamamoto T, Takano H. Adjunctive Catheter-Directed Thrombolysis during Primary PCI for ST-Segment Elevation Myocardial Infarction with High Thrombus Burden. J Clin Med 2022; 11:jcm11010262. [PMID: 35012003 PMCID: PMC8745791 DOI: 10.3390/jcm11010262] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/26/2021] [Accepted: 12/31/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND High coronary thrombus burden has been associated with unfavorable outcomes in patients with ST-segment elevation myocardial infarction (STEMI), the optimal management of which has not yet been established. METHODS We assessed the adjunctive catheter-directed thrombolysis (CDT) during primary percutaneous coronary intervention (PCI) in patients with STEMI and high thrombus burden. CDT was defined as intracoronary infusion of tissue plasminogen activator (t-PA; monteplase). RESULTS Among the 1849 consecutive patients with STEMI, 263 had high thrombus burden. Moreover, 41 patients received t-PA (CDT group), whereas 222 did not receive it (non-CDT group). No significant differences in bleeding complications and in-hospital and long-term mortalities were observed (9.8% vs. 7.2%, p = 0.53; 7.3% vs. 2.3%, p = 0.11; and 12.6% vs. 17.5%, p = 0.84, CDT vs. non-CDT). In patients who underwent antecedent aspiration thrombectomy during PCI (75.6% CDT group and 87.4% non-CDT group), thrombolysis in myocardial infarction grade 2 or 3 flow rate after thrombectomy was significantly lower in the CDT group than in the non-CDT group (32.2% vs. 61.0%, p < 0.01). However, the final rates improved without significant difference (90.3% vs. 97.4%, p = 0.14). CONCLUSIONS Adjunctive CDT appears to be tolerated and feasible for high thrombus burden. Particularly, it may be an option in cases with failed aspiration thrombectomy.
Collapse
Affiliation(s)
- Satsuki Noma
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Hideki Miyachi
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
- Correspondence: hidep-@nms.ac.jp; Tel.: +81-3-3822-2131
| | - Isamu Fukuizumi
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Junya Matsuda
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Hideto Sangen
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Yoshiaki Kubota
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Yoichi Imori
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Yoshiyuki Saiki
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Yusuke Hosokawa
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Shuhei Tara
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Yukichi Tokita
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Koichi Akutsu
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Wataru Shimizu
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Takeshi Yamamoto
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
| | - Hitoshi Takano
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| |
Collapse
|
2
|
Unzue L, Garcia E, Teijeiro R, Ginestal C, Fuertes B, Pastor A, Zorita B, Rodrigo FJR, Osende J, Parra FJ, Moreno L. Local Intracoronary Fibrinolysis in Acute Myocardial Infarction of Ectatic Coronary Arteries in the Post-Abciximab Era. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 32:69-74. [PMID: 33514487 DOI: 10.1016/j.carrev.2021.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 01/06/2021] [Indexed: 11/30/2022]
Abstract
Percutaneous intervention in the context of coronary artery ectasia (CAE) is penalized with no-reflow phenomenon. The glycoprotein-IIb/IIIa-inhibitor abciximab was the most accepted method for pharmacology thrombus resolution in this scenario, nevertheless, this agent was recently withdrawn. We describe 5 patients treated with local intracoronary fibrinolysis administrated through predesigned catheters in the setting of AMI and CAE.
Collapse
Affiliation(s)
- Leire Unzue
- Interventional Cardiology Unit, Hospital Universitario HM Montepríncipe, HM Hospitales, Madrid, Spain; San Pablo CEU University, Madrid, Spain; Interventional Cardiology Unit, Hospital Universitario HLA Moncloa, Madrid, Spain
| | - Eulogio Garcia
- Interventional Cardiology Unit, Hospital Universitario HM Montepríncipe, HM Hospitales, Madrid, Spain; Interventional Cardiology Unit, Hospital Universitario HLA Moncloa, Madrid, Spain
| | - Rodrigo Teijeiro
- Interventional Cardiology Unit, Hospital Universitario HM Montepríncipe, HM Hospitales, Madrid, Spain; Interventional Cardiology Unit, Hospital Universitario HLA Moncloa, Madrid, Spain
| | - Carmen Ginestal
- Intensive Care Unit, Hospital Universitario HM Madrid, HM Hospitales, Madrid, Spain
| | - Beatriz Fuertes
- Clinical Cardiology, Hospital Universitario HM Montepríncipe, HM Hospitales, Madrid, Spain
| | - Ana Pastor
- Clinical Cardiology, Hospital Universitario HM Montepríncipe, HM Hospitales, Madrid, Spain
| | - Blanca Zorita
- Clinical Cardiology, Hospital Universitario HM Montepríncipe, HM Hospitales, Madrid, Spain
| | | | - Julio Osende
- Clinical Cardiology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Francisco Javier Parra
- San Pablo CEU University, Madrid, Spain; Clinical Cardiology Unit, HM CIEC, Hospital Universitario HM Montepríncipe, Hospital Universitario HM Sanchinarro, Hospital Universitario HM Puerta del Sur, HM Hospitales, Madrid, Spain
| | - Leire Moreno
- Clinical Cardiology, Hospital Universitario HM Sanchinarro, HM Hospitales, Madrid, Spain
| |
Collapse
|
3
|
Agarwal SK, Agarwal S. Role of Intracoronary Fibrinolytic Therapy in Contemporary PCI Practice. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 20:1165-1171. [PMID: 30685340 DOI: 10.1016/j.carrev.2018.11.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 11/15/2018] [Accepted: 11/26/2018] [Indexed: 11/13/2022]
Abstract
Plaque rupture or plaque erosion leads to intracoronary thrombus formation resulting in coronary artery occlusion and ST-segment elevation myocardial infarction. Early restoration of blood flow in occluded coronary artery is the mainstay of therapy and it can be achieved by either thrombolytic therapy or primary percutaneous coronary intervention (P-PCI) or a combination of these two in many different ways. It has been proved that primary PCI is better than thrombolytic therapy in establishing early and effective recanalization of infarct related artery, reducing major adverse cardiovascular events (MACE) and increasing survival. There have been tremendous advances in PCI techniques over the years with newer stents, thrombectomy devices, and adjunctive pharmacotherapy. However, intracoronary thrombus continues to be the bane of interventional cardiologists. Failure of recanalization, suboptimal results, distal embolization, no reflow and impaired myocardial perfusion are some of the unresolved difficulties, regularly seen during PCI of patients with large intracoronary thrombus burden indicating an unmet need. This review focuses on emerging evidence about the usefulness of intracoronary thrombolytic therapy as an adjunct to PCI in patients with large intracoronary thrombus burden.
Collapse
Affiliation(s)
- Sanjeev Kumar Agarwal
- Department of Cardiology, Rashid Hospital, PO Box 4545, Dubai, United Arab Emirates.
| | - Shubham Agarwal
- Department of Internal Medicine, Rashid Hospital, Dubai, United Arab Emirates
| |
Collapse
|
4
|
Lee Y, Kim E, Kim BK, Shin JH. A case of successful reperfusion through a combination of intracoronary thrombolysis and aspiration thrombectomy in ST-segment elevation myocardial infarction associated with an ectatic coronary artery. BMC Cardiovasc Disord 2017; 17:94. [PMID: 28381215 PMCID: PMC5382492 DOI: 10.1186/s12872-017-0527-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 03/30/2017] [Indexed: 12/02/2022] Open
Abstract
Background Large thrombus burdens in ectatic coronary arteries that remain after aspiration thrombectomy can negatively impact outcomes following percutaneous coronary interventions in patients with acute myocardial infarction. Case presentation A 53-year-old man presented with ST-segment elevation myocardial infarction (STEMI). Coronary angiography revealed an ectatic right coronary artery (RCA) that was completely occluded in the mid portion by a large amount of thrombus. Catheter-directed intracoronary thrombolysis with alteplase led to recovery of coronary blood flow, which multiple attempts of aspiration thrombectomy had failed to achieve. Coronary angiography 9 days later showed good blood flow and insignificant stenosis remaining in the RCA; this had completely resolved in 6 months’ follow-up coronary angiography. Conclusion Catheter-directed intracoronary thrombolysis can be performed effectively and safely when repeat aspiration thrombectomy fails to produce satisfactory coronary reperfusion in STEMI patients with large thrombus burdens in ectatic coronary arteries.
Collapse
Affiliation(s)
- Yonggu Lee
- Division of Cardiology, Department of Internal Medicine, Hanyang University Guri Hospital, 153, Gyeongchun-ro, Guri-si, Gyeonggi-do, 11923, South Korea
| | - Eunjin Kim
- Division of Cardiology, Department of Internal Medicine, Hanyang University Guri Hospital, 153, Gyeongchun-ro, Guri-si, Gyeonggi-do, 11923, South Korea
| | - Bae Keun Kim
- Department of Cardiology, Sungae Hospital, Seoul, Republic of Korea
| | - Jeong-Hun Shin
- Division of Cardiology, Department of Internal Medicine, Hanyang University Guri Hospital, 153, Gyeongchun-ro, Guri-si, Gyeonggi-do, 11923, South Korea.
| |
Collapse
|
5
|
Grip L, Hellekant C, Herzfeld I, Malmberg K, Svane B, Szamosi A, Velander M, Ryden L. Coronary Angioplasty in Patients with Unstable Angina, with Special Reference to Preceding Treatment with Antithrombin III and Heparin. Clin Appl Thromb Hemost 2016. [DOI: 10.1177/107602969600200205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Seventy-nine patients undergoing percutane ous transluminal coronary angioplasty (PTCA) for unsta ble angina were analyzed with respect to preceding an tithrombin treatment; group I comprised patients (n = 26) without antecedent antithrombin therapy; group II, pa tients (n = 30) with heparin infusion for ≥24 h, and group III patients (n = 23) with ongoing heparin infusion and given antithrombin III concentrate immediately before the procedure because of plasma antithrombin III <85%. Immediate results were 89% (70 of 79) angiographic suc cess, five (6%) subacute occlusions (two subsequent non-Q wave infarctions), no emergency coronary artery bypass grafting (CABG), and no immediate mortality. There were no differences between the groups. From dis charge to 4 months, one patient died, one had a nonfatal infarction, and 24 (30%) had repeated PTCA or CABG. The cumulative 4-month event rate was 11 of 26 (42%) in group I, 10 of 30 (33%) in group II, and 7 of 23 (30%) in group III (NS). During PTCA, heparin bolus administra tion was guided by activated clotting time (ACT), aiming at>300 s. Baseline ACT was significantly less in patients not treated with heparin (129 ± 34 s in group I vs. 179 ± 38 and 162 ± 29 s in groups II and III, respectively; p < 0.05), but during the procedure, patients from all groups required the same amount of heparin (13,900 ± 4,800, 13,000 ± 6,800, and 13,000 ± 5,700 IU, respectively; NS) to reach similar maximum ACT levels (334 ± 36, 312 ± 32, and 319 ± 44 s, respectively; NS). Patients receiving warfarin ( n = 8) responded with a higher ACT (456 ± 110 s; p < 0.05) on lower doses of heparin (10,000 ± 3,800 IU). In conclusion, patients with unstable angina receiv ing individualized antithrombotic therapy can be success fully treated with PTCA, with an acute complication rate and long-term results comparable with those expected in patients undergoing elective procedures. The value of an tithrombin III substitution must be evaluated in random ized trials. Preprocedural heparin infusion does not re duce the need of extra heparin during the procedure. Key Words: Antithrombin III—Heparin—PTCA (percutane ous transluminal coronary angioplasty)—Unstable angina pectoris.
Collapse
Affiliation(s)
- Lars Grip
- Department of Cardiology, Karolinska Hospital
| | - Christer Hellekant
- Department of Thoracic Radiology, Karolinska Hospital, Stockholm, Sweden
| | - Istvan Herzfeld
- Department of Thoracic Radiology, Karolinska Hospital, Stockholm, Sweden
| | | | - Bertil Svane
- Department of Thoracic Radiology, Karolinska Hospital, Stockholm, Sweden
| | - Alfred Szamosi
- Department of Thoracic Radiology, Karolinska Hospital, Stockholm, Sweden
| | - Mats Velander
- Department of Thoracic Radiology, Karolinska Hospital, Stockholm, Sweden
| | - Lars Ryden
- Department of Cardiology, Karolinska Hospital
| |
Collapse
|
6
|
|
7
|
Boscarelli D, Vaquerizo B, Miranda-Guardiola F, Arzamendi D, Tizon H, Sierra G, Delgado G, Fantuzzi A, Estrada D, Garcia-Picart J, Cinca J, Serra A. Intracoronary thrombolysis in patients with ST-segment elevation myocardial infarction presenting with massive intraluminal thrombus and failed aspiration. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 3:229-36. [DOI: 10.1177/2048872614527008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Daniela Boscarelli
- Department of Cardiology, Hospital de la Santa Creu y Sant Pau, Barcelona, Spain
| | - Beatriz Vaquerizo
- Department of Cardiology, Hospital de la Santa Creu y Sant Pau, Barcelona, Spain
| | | | - Dabit Arzamendi
- Department of Cardiology, Hospital de la Santa Creu y Sant Pau, Barcelona, Spain
| | - Helena Tizon
- Department of Cardiology, Hospital Parc de salut Mar, Barcelona, Spain
| | - Gilberto Sierra
- Department of Cardiology, Hospital Parc de salut Mar, Barcelona, Spain
| | - Guillermo Delgado
- Department of Cardiology, Hospital de la Santa Creu y Sant Pau, Barcelona, Spain
| | - Andres Fantuzzi
- Department of Cardiology, Hospital Parc de salut Mar, Barcelona, Spain
| | - Darlene Estrada
- Department of Cardiology, Hospital de la Santa Creu y Sant Pau, Barcelona, Spain
| | - Joan Garcia-Picart
- Department of Cardiology, Hospital de la Santa Creu y Sant Pau, Barcelona, Spain
| | - Juan Cinca
- Department of Cardiology, Hospital de la Santa Creu y Sant Pau, Barcelona, Spain
| | - Antonio Serra
- Department of Cardiology, Hospital de la Santa Creu y Sant Pau, Barcelona, Spain
| |
Collapse
|
8
|
Huang PH, Bhatt DL. Adjunctive Pharmacotherapy for Thrombotic Coronary Lesions. Interv Cardiol Clin 2013; 2:375-387. [PMID: 28582143 DOI: 10.1016/j.iccl.2012.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Patients with unstable coronary syndromes are often found to have intracoronary thrombus on angiography. Despite advancements in catheter-based treatments for coronary disease, these lesions remain challenging, as percutaneous coronary intervention of thrombus-containing lesions may be associated with worse outcomes. This article reviews the literature on adjunctive pharmacotherapy in the treatment of thrombotic coronary lesions with special focus on ST-segment elevation myocardial infarction, lesions with high thrombus burden, and saphenous vein graft intervention.
Collapse
Affiliation(s)
- Pei-Hsiu Huang
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA; Integrated Interventional Cardiovascular Program, Cardiovascular Division, VA Boston Healthcare System, 1400 VFW Parkway, Boston, MA 02132, USA.
| |
Collapse
|
9
|
Kim JS, Kim JH, Jang HH, Lee YW, Song SG, Park JH, Chun KJ. Successful Revascularization of Coronary Artery Occluded by Massive Intracoronary Thrombi with Alteplase and Percutaneous Coronary Intervention. J Atheroscler Thromb 2010; 17:768-70. [DOI: 10.5551/jat.4283] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
|
10
|
Bejarano J. Mechanical protection of cardiac microcirculation during percutaneous coronary intervention of saphenous vein grafts. Int J Cardiol 2005; 99:365-72. [PMID: 15771915 DOI: 10.1016/j.ijcard.2004.05.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2003] [Revised: 04/30/2004] [Accepted: 05/05/2004] [Indexed: 10/26/2022]
Abstract
Saphenous vein bypass grafts permeability is one of the most important limitations of open heart surgery. The risks associated with surgical re-intervention are greater than those associated with the initial procedure. While native coronary arteries usually have fixed, fibrotic or calcified atherosclerotic plaques, the disease in the vein grafts contains soft material. When this material is compressed during percutaneous angioplasty, there is an unfavorable immediate outcome due to distal embolization of thrombus and plaque debris. In addition, the risk of post-procedure adverse events are higher when the grafts have a long time of implantation, due to a greater risk of branch occlusion or no-reflow at the adjacent microcirculation. The clinical consequence is a Non-Q-Wave Myocardial Infarction that is reflected in the increased serum cardiac enzymes. It is because of this complication that the distal protection devices were developed. The purpose of this paper is to review and discuss the current data on the distal protection devices available now for the treatment of degenerative saphenous vein graft disease. Currently, there are two distal protection devices approved in the United States: the Guardwire Balloon and Aspiration (Export) System and the Filter Wire EX. Other devices like the Triactiv System, Angioguard XP/ECW, DOW, MedNova Cardioshield, Medtronic-AVE DPD and the E-Trap Filter are still being studied. The first observational studies showed the safety and efficacy of the approved devices. A large randomized trial initially confirmed a significant decrease of in-hospital and 30-day cardiac adverse events, mainly Non-Q-Wave Myocardial Infarction, when angioplasty was performed with the assistance of the Guardwire System. Subsequently, another randomized study showed an equivalence between the Guardwire System and the Filter Wire EX. Distal protection devices have an acceptable performance, however, further technological improvements are warranted for a quick preparation, delivery and/or retrieval of these devices.
Collapse
Affiliation(s)
- Jorge Bejarano
- Miami Heart Institute, Cardiovascular Laboratory, 4701 North Meridian Avenue, Suite 3303, Miami Beach, FL 33140, USA.
| |
Collapse
|
11
|
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. JAPANESE CIRCULATION JOURNAL 2001; 65:251-6. [PMID: 11316117 DOI: 10.1253/jcj.65.251] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Thrombus in the infarct-related artery is one of the limitations for flow restoration in primary percutaneous transluminal coronary angioplasty (PTCA) treatment for acute myocardial infarction (AMI). The present study investigated the benefit of preceding intracoronary thrombolysis (ICT) by retrospectively analyzing acute phase flow restoration in 80 AMI patients with intracoronary thrombus: 40 undergoing primary PTCA alone (primary PTCA group) and 40 treated with preceding ICT plus PTCA (combined group). Acute phase Thrombolysis in Myocardial Infarction (TIMI) grade flow was as follows: TIMI 0/1: 35.0% vs 12.5% for the primary PTCA group and the combined group, p=0.06; TIMI 2: 7.5% vs 15.0%, p=NS; TIMI 3: 57.5% vs 72.5%, p=NS). In the subgroup analysis, it was also less in the combined group among 33 patients with a left anterior descending coronary artery (LAD) lesion (42.1 % vs 7.1%, p=0.08), but not among the remaining 47 with either a right coronary artery or left circumflex artery lesion. The combined therapy may potentially provide better acute phase flow restoration in AMI patients with an intracoronary thrombus in a LAD lesion.
Collapse
Affiliation(s)
- F Ishibashi
- Cardiovascular Division, Kumamoto Central Hospital, Japan
| | | | | | | | | | | |
Collapse
|
12
|
|
13
|
Wheeldon N, Cumberland D. Pharmacologic prevention of acute ischemic complications of coronary angioplasty. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1997; 42:249-56. [PMID: 9367094 DOI: 10.1002/(sici)1097-0304(199711)42:3<249::aid-ccd2>3.0.co;2-c] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The risk of acute coronary occlusion following percutaneous transluminal coronary angioplasty (PTCA) has remained high despite the traditional use of heparin and aspirin. Interest has focused on newer strategies for preventing intracoronary thrombus formation, which is an important mechanism of abrupt vessel closure. Pretreatment with thrombolytic agents has failed vigorous testing in double-blind trials. Retrospective and observational studies have indicated that pretreatment with intravenous heparin is of benefit in patients with unstable symptoms, but prolonged infusion after angioplasty increases bleeding complications without improving outcomes. Subcutaneous heparin may be safer, but has not proved more effective. Oral dipyridamole has shown no advantage over aspirin, although there is evidence to suggest a benefit when given intravenously. Direct thrombin inhibitors (such as hirudin and hirulog) are associated with fewer early complications compared with heparin, but have yielded no apparent long-term benefit. The use of the antiplatelet drug ticlopidine is increasing, although long-term data are lacking. A great deal of recent interest has focused on newer antiplatelet agents, particularly the glycoprotein IIB/IIIa receptor inhibitor c7E3 Fab. In a large-scale trial, c7E3 significantly reduced the 30-day rate of mortality and cardiac events, and these benefits were maintained at 6 mo. This drug, unlike other antiplatelet agents, inhibits the final common pathway of platelet aggregation, which influences not only acute closure but has lasting effects for at least 6 mo. This may reflect a reduction in restenosis, although this remains to be proven. This article gives a brief overview of the pharmacologic agents available for the prophylaxis and treatment of acute ischemic complications of PTCA.
Collapse
Affiliation(s)
- N Wheeldon
- Cardiothoracic Unit, Northern General Hospital National Health Service Trust, Sheffield, United Kingdom
| | | |
Collapse
|
14
|
Mitchel JF, Shwedick M, Alberghini TA, Knibbs D, McKay RG. Catheter-based local thrombolysis with urokinase: comparative efficacy of intraluminal clot lysis with conventional urokinase infusion techniques in an in vivo porcine thrombus model. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1997; 41:293-302. [PMID: 9213028 DOI: 10.1002/(sici)1097-0304(199707)41:3<293::aid-ccd10>3.0.co;2-p] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Local delivery of urokinase directly to the site of intraluminal clot using catheter-based technology has recently been introduced as a new technique to treat intracoronary thrombus and thrombus-containing stenoses. The purpose of this study was to compare the efficacy of urokinase therapy administered by local drug-delivery catheters with conventional urokinase-infusion techniques in dissolving intraluminal clot and intramurally depositing drug at the site of arterial injury in an in vivo porcine model. Five techniques of urokinase administration were studied in 65 pigs, including intravenous systemic bolus (1,000,000 units), guiding catheter infusion (500,000 units), local intraluminal infusion with a Roubin catheter (150,000 units), local infusion by the Dispatch catheter (150,000 units), and local delivery by the hydrogel-coated balloon (700 units). All five techniques were initially compared with respect to the quantity of intraluminal lysis of 123I-fibrinogen-labeled thrombus in an in vivo thrombus model. Conventional balloon angioplasty was also assessed in this model as a nonpharmacologic, mechanical control. In addition, all five techniques were compared with respect to the quantity and efficiency of intramural urokinase deposition at coronary angioplasty sites. In the in vivo thrombolysis experiments, the quantity of artificial clot lysis measured 6.8% for systemic therapy, 20.8% for guiding catheter infusion, 25.2% for Roubin catheter infusion, 62.8% for Dispatch catheter infusion, 98.8% for hydrogel balloon delivery, and 53.6% for conventional balloon angioplasty. Both the Dispatch catheter and the hydrogel balloon resulted in more clot lysis than the systemic, guiding catheter, or Roubin catheter approaches (P < 0.05). In comparison with conventional balloon angioplasty, only the hydrogel balloon resulted in higher levels of thrombus dissolution (P < 0.05). In the intramural deposition studies, the efficiency of urokinase delivery was 0.0004% for systemic therapy, 0.004% for guiding catheter infusion, 0.004% for Roubin catheter infusion, 0.08% for Dispatch catheter infusion, and 1.8% for hydrogel balloon delivery. The Dispatch catheter resulted in higher intramural drug levels than did all other techniques (P < 0.05), whereas the efficiency of urokinase deposition was higher with the hydrogel balloon than with all other approaches (P < 0.05). In the porcine model, it is subsequently concluded that local delivery of urokinase by catheter-based techniques can result in more complete lysis of intraluminal thrombus by using similar or lower doses of drug than by using conventional urokinase infusion techniques. Mechanical deformation of thrombus, possibly to increase the surface area available for thrombolysis and to physically disrupt clot, may be an important component of the mechanism of site-specific thrombolysis, particularly with the hydrogel balloon. Local delivery techniques also deposit significant quantities of urokinase at balloon angioplasty sites, creating an intramural reservoir of drug that may result in prolonged local thrombolysis.
Collapse
Affiliation(s)
- J F Mitchel
- Department of Internal Medicine, Hartford Hospital, University of Connecticut 06115, USA
| | | | | | | | | |
Collapse
|
15
|
Boston DR, Malouf A, Barry WH. Management of intracoronary thrombosis complicating percutaneous transluminal coronary angioplasty. Clin Cardiol 1996; 19:536-42. [PMID: 8818433 DOI: 10.1002/clc.4960190704] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
With technological advances in equipment and increased experience of operators, the success rates of percutaneous transluminal coronary angioplasty (PTCA) now exceed 90%. However, acute periprocural occlusion continues to complicate approximately 6% of all procedures, and many of these occlusions are due to intracoronary (IC) thrombus. Patients at highest risk for this complication include those with acute ischemic syndromes or with angiographically apparent thrombus. These individuals may be candidates for the use of prolonged heparin infusions prior to dilatation, intracoronary thrombolytic therapy, or monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor. All patients undergoing PTCA should receive adequate antiplatelet therapy, including aspirin, and heparin with dosing monitored by activated clotting times (ACT). In addition, some recommend the use of ionic contrast material. When IC thrombus accumulates following intervention, initial therapy should include IC nitroglycerin followed by a combination of redilatation and IC urokinase infusion. Prolonged balloon inflations may be useful, particularly with the use of autoperfusion catheters. Platelet glycoprotein IIb/IIIa receptor antagonists may prove to be beneficial in this situation as well. If the patient's clinical status deteriorates in spite of these measures, emergency coronary artery bypass graft surgery may be required.
Collapse
Affiliation(s)
- D R Boston
- Division of Cardiology, University of Utah Medical Center, Salt Lake City 84132, USA
| | | | | |
Collapse
|
16
|
Gurbel PA, Navetta FI, Bates ER, Muller DW, Tenaglia AN, Miller MJ, Muhlstein B, Hermiller JB, Davidson CJ, Aguirre FV, Beauman GJ, Berdan LG, Leimberger JD, Bovill EG, Christenson RH, Ohman EM. Lesion-directed administration of alteplase with intracoronary heparin in patients with unstable angina and coronary thrombus undergoing angioplasty. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1996; 37:382-91. [PMID: 8721695 DOI: 10.1002/(sici)1097-0304(199604)37:4<382::aid-ccd8>3.0.co;2-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Percutaneous coronary revascularization in patients with unstable angina and coronary thrombus carries a high complication rate. A new strategy to reduce thrombus burden before revascularization was tested in a multicenter prospective trial. Patients with unstable angina and coronary thrombus (n = 45) received alteplase through an infusion catheter at the proximal aspect of the target lesion and concomitant intracoronary heparin via a standard guiding catheter. Angiography was performed before and alter lesion-directed therapy and post-intervention. Systemic fibrinogen depletion and thrombin activation were not observed, while fibrinolysis was evident for > or = 4 hr after treatment. Target lesion stenosis did not change significantly after lesion-directed therapy, but thrombus score was reduced, particularly among patients who had large thrombi (mean 2.2 vs. 1.6, P = 0.02). Revascularization was successful in 89% of patients. Median final stenosis was 30% and mean final thrombus score was 0.4. Complications included recurrent ischemia (11%), MI (7%), abrupt closure (7%), severe bleeding (4%), and repeat emergency angioplasty (2%). Patients with overt thrombus appeared to derive the most angiographic benefit from lesion-directed alteplase plus intracoronary heparin. Later revascularization was highly successful. This strategy may be a useful adjunct to percutaneous revascularization for patients with unstable angina and frank intracoronary thrombus.
Collapse
Affiliation(s)
- P A Gurbel
- Department of Medicine, University of Maryland Medical System, Baltimore, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Kaplan BM, Safian RD, Goldstein JA, Grines CL, O'Neill WW. Efficacy of angioscopy in determining the effectiveness of intracoronary urokinase and TEC atherectomy thrombus removal from an occluded saphenous vein graft prior to stent implantation. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1995; 36:335-7. [PMID: 8719385 DOI: 10.1002/ccd.1810360411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Percutaneous revascularization of thrombus containing saphenous vein grafts is associated with a high incidence of acute complications. This case report describes successful revascularization of an occluded vein graft employing angioscopically guided sequential urokinase infusion, TEC atherectomy and stent implantation.
Collapse
Affiliation(s)
- B M Kaplan
- William Beaumont Hospital, Royal Oak, Michigan 48073, USA
| | | | | | | | | |
Collapse
|
18
|
Mehran R, Ambrose JA, Bongu RM, Almeida OD, Israel DH, Torre S, Sharma SK, Ratner DE. Angioplasty of complex lesions in ischemic rest angina: results of the Thrombolysis and Angioplasty in Unstable Angina (TAUSA) trial. J Am Coll Cardiol 1995; 26:961-6. [PMID: 7560624 DOI: 10.1016/0735-1097(95)00271-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES This study sought to analyze the role of complex lesion morphology on the acute results of angioplasty. BACKGROUND Acute complications of angioplasty are higher in unstable than in stable angina. The unstable culprit lesion is usually complex, indicative of plaque disruption and thrombus formation. Previous nonrandomized studies have shown that the presence of intracoronary thombus increases morbidity after coronary angioplasty. The role of complex morphology in coronary angioplasty outcome was studied in a prespecified subgroup analysis of a large multicenter coronary angioplasty trial. METHODS The results of coronary angioplasty from the Thrombolysis and Angioplasty in Unstable Angina (TAUSA) trial were analyzed. This large trial randomized 469 patients in double-blinded manner to receive either intracoronary urokinase or placebo during coronary angioplasty of the culprit lesion in ischemic rest angina with or without recent infarction. The study presented here analyzes in detail the results of coronary angioplasty in complex versus simple lesions in the urokinase and placebo groups. Complex lesions were defined before angioplasty by a core laboratory as having one or more of the following: irregular borders, overhanging edges, ulcerations or intraluminal filling defects proximal or distal to the lesion. RESULTS Of the 469 patients, 458 had identifiable culprit lesions, of which 245 were complex and 213 were simple. Complex lesions were associated with a higher abrupt closure rate than simple lesions (10.6% vs. 3.3%, respectively, p < 0.003). Patients with complex lesions also had higher recurrent in-hospital angina (p < 0.02) and emergent bypass surgery (p < 0.02). Further analysis of complex lesions revealed that abrupt closure was particularly high in the urokinase group (15.0% vs 5.9% for the placebo group, p < 0.03), and most abrupt closures were thrombotic. Composite clinical end points were also significantly higher with complex lesions and urokinase. In the placebo group, complex lesions had a higher abrupt closure rate as well as postcoronary angioplasty filling defects, but clinical end points were not significantly different. CONCLUSIONS Complex lesions before coronary angioplasty increase acute complication rates after coronary angioplasty. Urokinase as administered in the TAUSA trial had significant adverse effects, especially in complex lesions. However, even in the placebo arm, complex lesions were associated with higher complication rates than simple lesions. Newer antithrombotic measures that particularly target the platelet may eventually decrease complication rates in these lesions.
Collapse
Affiliation(s)
- R Mehran
- Department of Medicine, Mount Sinai Hospital, New York, New York, USA
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Dehmer GJ, Gresalfi N, Daly D, Oberhardt B, Tate DA. Impairment of fibrinolysis by streptokinase, urokinase and recombinant tissue-type plasminogen activator in the presence of radiographic contrast agents. J Am Coll Cardiol 1995; 25:1069-75. [PMID: 7897118 DOI: 10.1016/0735-1097(94)00528-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES The purpose of this study was to determine whether an adverse interaction exists between radiographic contrast agents and thrombolytic drugs. BACKGROUND Coronary thrombosis may occur in the setting of unstable angina and after coronary angioplasty. However, the use of thrombolytic drugs in the setting of unstable angina has not been beneficial and, in one large trial of angioplasty in patients with unstable angina, was associated with an increased incidence of ischemic complications and abrupt closure. The reasons for these results are not clear. Coronary arteriography was performed in many of these trials, and it is known that fibrin structure and assembly are altered by radiographic contrast agents. METHODS Blood samples were obtained from patients before (n = 25) and after (n = 20) angiography using iohexol. Blood samples obtained before angiography were tested for response to streptokinase (10 and 100 IU/ml), urokinase (100, 200 and 500 IU/ml) and recombinant tissue-type plasminogen activator (rt-PA) (100 and 1,000 IU/ml) and the results measured. Iohexol, diatrizoate or ioxaglate (4% by volume) was added to separate aliquots of the baseline sample, and the test was repeated. Blood samples obtained after angiography were tested in a similar manner. RESULTS The onset of lysis at baseline by rt-PA at 1,000 IU/ml occurred at 72 +/- 8.2 s (mean +/- SD) and was markedly delayed in the presence of diatrizoate (527 +/- 181.7 s, p < 0.001) or iohexol (460 +/- 197.0 s, p < 0.001) but not ioxaglate. At 100 IU/ml, there was no lysis detected with rt-PA after the addition of any contrast agent. The addition of a contrast agent caused similar delays in the onset of lysis by urokinase and streptokinase; similar to rt-PA, the effect was smaller at higher concentrations of drug. In vivo blood samples obtained from the patient after angiography showed delays in the onset of lysis by rt-PA and urokinase but not streptokinase. CONCLUSIONS These data demonstrate that radiographic contrast agents impede fibrinolysis. This previously undescribed interaction was demonstrated using an in vitro test system, but these findings may have clinical relevance when thrombolytic drugs are used at the time of angiography.
Collapse
Affiliation(s)
- G J Dehmer
- C. V. Richardson Cardiac Catheterization Laboratory, University of North Carolina Hospitals, Chapel Hill 27514
| | | | | | | | | |
Collapse
|
20
|
Mitchel JF, Fram DB, Palme DF, Foster R, Hirst JA, Azrin MA, Bow LM, Eldin AM, Waters DD, McKay RG. Enhanced intracoronary thrombolysis with urokinase using a novel, local drug delivery system. In vitro, in vivo, and clinical studies. Circulation 1995; 91:785-93. [PMID: 7828307 DOI: 10.1161/01.cir.91.3.785] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Current pharmacological regimens for treating intracoronary thrombus in the cardiac catheterization laboratory generally involve the administration of thrombolytic agents that result in a systemic fibrinolytic state and/or require prolonged arterial drug infusion. The purpose of the present study was to assess a new technique for treating intracoronary thrombus consisting of the local infusion of limited quantities of urokinase with a novel drug delivery device. METHODS AND RESULTS THe Dispatch coronary infusion catheter is a new local drug delivery system that allows for the prolonged infusion of therapeutic agents at an angioplasty site while distal coronary flow is maintained. Three experimental protocols were performed to determine the in vitro, in vivo, and clinical efficacy of this device. First, in vitro thrombolysis of fresh, porcine thrombus trapped in a 4-mm plastic tube with a 50% constriction and perfused with 20% porcine plasma was measured. Twenty-three thrombi were weighed before and after no treatment (n = 5), "systemic" urokinase administration (n = 4), local infusion of 150,000 U urokinase with a standard end-hole catheter (n = 4), local infusion of saline with the Dispatch catheter (n = 5), and local infusion of 150,000 U urokinase with the Dispatch catheter (n = 5). Second, 25 porcine coronary arteries in 23 pigs were dilated in vivo with conventional balloon angioplasty and then treated with 123I-labeled urokinase that was administered either by the Dispatch catheter (150,000 U; n = 16), intravenous systemic bolus (1,000,000 U; n = 3), guiding catheter infusion (500,000 U; n = 3), or local end-hole catheter infusion (150,000 U; n = 3). All vessels were subsequently harvested to quantify intramural deposition and subsequent washout of urokinase at the angioplasty site. Finally, 19 patients with angiographic evidence of intracoronary thrombus were treated with local urokinase infusion with the Dispatch catheter either before or after balloon angioplasty or directional atherectomy. In vitro studies demonstrated that infusion of urokinase with the Dispatch catheter decreased thrombus weight by 66% compared with no treatment (-25%), "systemic" urokinase administration (25%), end-hole catheter urokinase infusion (32%), or infusion of saline by the Dispatch catheter (32%) (P < or = .005). In vivo studies demonstrated immediate deposition of 0.12% of the urokinase delivered by the Dispatch catheter to the angioplasty site, compared with 0.0007% with systemic bolus, 0.003% with guiding catheter infusion, and 0.007% with local infusion with an end-hole catheter (P < .001). Urokinase deposited by the Dispatch catheter persisted intramurally for at least 5 hours. Patient studies demonstrated reduction of thrombus-containing stenoses and complete disappearance of intracoronary thrombus in all cases in which 150,000 U urokinase was locally infused over 30 minutes. There was no evidence of abrupt closure, distal embolization, or no reflow in any patient. CONCLUSIONS Local urokinase delivery with the Dispatch catheter can result in rapid and complete intracoronary thrombolysis using substantially less drug than standard thrombolytic techniques. Intramural deposition of drug with this technique creates a local reservoir of urokinase that may provide prolonged thrombolytic activity at the infusion site.
Collapse
Affiliation(s)
- J F Mitchel
- Department of Internal Medicine, Hartford Hospital, University of Connecticut 06115
| | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Mehan VK, Kaufmann U, Salzmann C, Meier B. Use of half (disarticulated) Palmaz-Schatz stents for thrombus-containing coronary lesions. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1994; 33:370-2. [PMID: 7889561 DOI: 10.1002/ccd.1810330420] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Coronary stenoses associated with thrombus can lead to poor angioplasty results and increased procedural complications. Stenting in the presence of thrombus is associated with an increased risk of stent thrombosis. We report eight patients in whom half a Palmaz-Schatz stent was implanted for inadequate angioplasty results owing to thrombus. Stenting resulted in improved angioplasty results; no stent thrombosis occurred.
Collapse
Affiliation(s)
- V K Mehan
- Department of Cardiology, University Hospital, Bern, Switzerland
| | | | | | | |
Collapse
|
22
|
Yakubov SJ, George BS, Chapekis AT. Adjunctive Thrombolytic Agents With Coronary Interventional Techniques. Cardiol Clin 1994. [DOI: 10.1016/s0733-8651(18)30076-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
23
|
Vaitkus PT, Laskey WK. Efficacy of adjunctive thrombolytic therapy in percutaneous transluminal coronary angioplasty. J Am Coll Cardiol 1994; 24:1415-23. [PMID: 7930268 DOI: 10.1016/0735-1097(94)90128-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Adjunctive thrombolysis has not been shown to improve angioplasty success or complication rates in elective angioplasty or myocardial infarction and may be detrimental in unstable angina. Thrombolysis of chronically occluded vessels achieves recanalization at a rate comparable to conventional angioplasty and is associated with a high rate of complications and limited long-term patency. Thrombolysis administered for thrombus or acute occlusion complicating angioplasty usually achieves coronary artery patency but is unable to forestall complications in many cases. A benefit of thrombolysis in reducing restenosis has not been conclusively demonstrated.
Collapse
Affiliation(s)
- P T Vaitkus
- Cardiology Unit, Medical Center Hospital of Vermont, University of Vermont, Burlington 05401
| | | |
Collapse
|
24
|
McKay RG, Fram DB, Hirst JA, Kiernan FJ, Primiano CA, Rinaldi MJ, Azrin MA, Mitchel JF, Waters DD. Treatment of intracoronary thrombus with local urokinase infusion using a new, site-specific drug delivery system: the Dispatch catheter. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1994; 33:181-8. [PMID: 7834736 DOI: 10.1002/ccd.1810330223] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND The presence of intracoronary thrombus significantly increases the risk of conventional balloon angioplasty because of a high incidence of abrupt closure, distal embolization, and no-reflow phenomenon. The purpose of this study was to assess a new technique for treating intracoronary thrombus consisting of the local delivery of urokinase directly to the angioplasty site with a novel, catheter-based, drug delivery system. METHODS The Dispatch catheter is a new local, drug-delivery device that allows for the prolonged infusion of therapeutic agents at an angioplasty site while still maintaining distal coronary perfusion. Six patients with angiographic or clinical evidence of intracoronary thrombus were treated with 150,000 units of urokinase over a 30-min period using this device prior to or following conventional balloon angioplasty and/or directional atherectomy. RESULTS Successful delivery of urokinase directly to the angioplasty site was achieved in all 6 patients without hemodynamic or electrocardiographic compromise. In all six cases, local urokinase therapy resulted in complete dissolution of angiographic intracoronary thrombus and/or reduction of the coronary stenosis. Limited ischemia due to side-branch occlusion by the catheter's coils was noted in one patient. Distal embolization or no-reflow phenomenon were not observed in any case. CONCLUSION The local drug-delivery catheter used in this study was able to successfully and rapidly achieve intracoronary thrombolysis by delivering limited quantities of urokinase directly to the angioplasty site, while still maintaining distal coronary perfusion. This technique of local, thrombolytic drug delivery may be useful in the percutaneous treatment of intracoronary thrombus and thrombus-containing stenoses.
Collapse
Affiliation(s)
- R G McKay
- Department of Internal Medicine, Hartford Hospital, University of Connecticut 06115
| | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Mitchel JF, Azrin MA, Fram DB, Hong MK, Wong SC, Barry JJ, Bow LM, Curley TM, Kiernan FJ, Waters DD. Inhibition of platelet deposition and lysis of intracoronary thrombus during balloon angioplasty using urokinase-coated hydrogel balloons. Circulation 1994; 90:1979-88. [PMID: 7923688 DOI: 10.1161/01.cir.90.4.1979] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Conventional balloon angioplasty of intracoronary thrombus is associated with a high incidence of abrupt closure, distal embolization, and no-reflow phenomenon. The purpose of this study was to assess a new technique for treating intracoronary thrombus consisting of the local delivery of urokinase directly to the angioplasty site with urokinase-coated hydrogel balloons. METHODS AND RESULTS We assessed local urokinase delivery using hydrogel balloons in four protocols. First, we evaluated the pharmacokinetics of urokinase delivery in vitro using 125I-labeled urokinase to measure drug loading onto hydrogel balloons, drug retention by the hydrogel polymer during blood exposure, and drug transfer from the balloon surface to the arterial wall during balloon dilatation. Second, we measured 125I-urokinase washoff from the hydrogel balloon in the intact circulation and intramural drug delivery during in vivo balloon angioplasty in 10 anesthetized New Zealand rabbits. Third, we assessed the effect of local urokinase delivery on 111In-labeled platelet deposition after balloon angioplasty in vivo in 13 porcine carotid or iliac arteries dilated with urokinase-coated balloons and compared them with contralateral control arteries dilated with saline-coated balloons. Finally, we determined the clinical efficacy of urokinase-coated balloons in 15 patients with intracoronary thrombus, including 7 who demonstrated abrupt thrombotic closure after conventional angioplasty. Between 241 and 1509 U urokinase could be loaded onto hydrogel balloons ranging in size from 2 to 8 mm. In vitro and in vivo studies demonstrated that hydrogel balloons absorbed significantly more urokinase and demonstrated less drug wash-off than nonhydrogel balloons (P < .01). Similarly, both in vitro and in vivo studies demonstrated urokinase transfer from the hydrogel to the arterial wall during balloon angioplasty, with greater intramural drug deposition with larger balloons (P < .01). Local urokinase delivery after in vivo porcine angioplasty decreased 111In-labeled platelet deposition by 47% compared with contralateral control vessels (P = .03). Use of urokinase-coated balloons in patients with intracoronary thrombus resulted in thrombus dissolution and reversal of abrupt closure in all cases, without evidence of distal embolization. CONCLUSIONS With the use of hydrogel-coated balloons, urokinase can be delivered locally to an angioplasty site. This technique decreases platelet deposition after in vivo balloon angioplasty and is efficacious in treating intracoronary thrombus in patients, including those with abrupt thrombotic closure.
Collapse
Affiliation(s)
- J F Mitchel
- Department of Internal Medicine, Hartford Hospital, University of Connecticut 06115
| | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Kjellgren O, Wilentz JR, Kaganovsky L, Sherman W. Prolonged intracoronary infusion of streptokinase: an alternative pharmacologic approach to extensive thrombus in native coronary artery. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1994; 33:80-4. [PMID: 8001107 DOI: 10.1002/ccd.1810330118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Several reports suggest that pretreatment of intracoronary thrombus with fibrinolytic agents may reduce the risk for complications during subsequent balloon angioplasty. We report a case, for the first time, of successful lysis of an extensive thrombus in a native coronary artery by administering a prolonged intracoronary infusion of streptokinase to facilitate subsequent angioplasty and discuss the management strategy when intracoronary thrombus is encountered.
Collapse
Affiliation(s)
- O Kjellgren
- Beth Israel Medical Center, New York, New York 10003
| | | | | | | |
Collapse
|
27
|
Ambrose JA, Almeida OD, Sharma SK, Torre SR, Marmur JD, Israel DH, Ratner DE, Weiss MB, Hjemdahl-Monsen CE, Myler RK. Adjunctive thrombolytic therapy during angioplasty for ischemic rest angina. Results of the TAUSA Trial. TAUSA Investigators. Thrombolysis and Angioplasty in Unstable Angina trial. Circulation 1994; 90:69-77. [PMID: 8026054 DOI: 10.1161/01.cir.90.1.69] [Citation(s) in RCA: 100] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Acute closure is increased after angioplasty in unstable angina, and adjunctive intracoronary thrombolytic therapy has been used successfully to increase angiographic success. The role of prophylactic thrombolytic therapy during angioplasty in unstable angina is unknown. METHODS AND RESULTS Four hundred sixty-nine patients with ischemic rest pain with or without a recent (< 1 month) infarction were randomized in double-blind fashion to intracoronary urokinase or placebo. Randomization was carried out in two sequential phases. In phase I, 257 patients were randomized to 250,000 U of urokinase or placebo given in divided doses at the time of angioplasty. In phase II, 212 patients were randomized to 500,000 U of urokinase or placebo in divided doses. All patients were pretreated with aspirin, and activated clotting times were followed to maintain them at > 300 seconds during angioplasty. Angiographic end points of thrombus after angioplasty were insignificantly decreased by urokinase (30 [13.8%] versus 41 [18.0%] with placebo; P = NS). Acute closure, on the other hand, was increased with urokinase (23 [10.2%] versus 10 [4.3%] with placebo; P < .02). The difference in acute closure between urokinase and placebo was more striking at the higher dose of urokinase (P < .04) than in phase I at the lower urokinase dose (P = NS). Adverse in-hospital clinical end points (ischemia, infarction, or emergency coronary artery bypass surgery) were also increased with urokinase versus placebo (30 [12.9%] versus 15 [6.3%], respectively; P < .02). Angiographic and clinical end points were worse with urokinase in unstable angina without recent infarction than with angioplasty after a recent infarction. CONCLUSIONS Adjunctive urokinase given prophylactically during angioplasty for ischemic rest angina as administered in this trial is associated with adverse angiographic and clinical events. These detrimental effects may be related to hemorrhagic dissection, lack of intimal sealing, or procoagulant or platelet-activating effects of urokinase.
Collapse
Affiliation(s)
- J A Ambrose
- Department of Medicine, Mount Sinai Medical Center, New York, NY 10029
| | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Shibley MH, Clifton GD. Febrile reaction associated with urokinase. Pharmacotherapy 1994; 14:123-5. [PMID: 8159597 DOI: 10.1002/j.1875-9114.1994.tb02797.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Urokinase is an endogenously produced human proteolytic enzyme used to treat many thrombotic disorders. A 54-year-old man with recurrent myocardial infarction experienced fever during intracoronary urokinase infusion into a saphenous vein graft; the fever resolved after discontinuation of the infusion. After excluding all other possible etiologies of fever, urokinase was determined to be the cause. Several studies indicated that this reaction may be associated with urokinase infusion, but it is actually recognized by few individuals. This is the first published case report of the adverse event to our knowledge.
Collapse
Affiliation(s)
- M H Shibley
- Division of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky Medical Center, Lexington
| | | |
Collapse
|
29
|
Abstract
Acute coronary occlusion following angioplasty is a significant cause of in-hospital morbidity and mortality. Following acute closure, several strategies can be used to reopen the artery, including redilation, adjunctive thrombolysis, or other interventional techniques. Definite indications for thrombolysis as an adjunct to angioplasty include (1) recently occluded saphenous vein grafts, patent native vessels, or saphenous grafts with abundant intracoronary thrombus; and (2) acute closure during angioplasty, which is presumably secondary to thrombus formation and resistant to redilation alone.
Collapse
Affiliation(s)
- J A Ambrose
- Department of Medicine, Mount Sinai Hospital, New York, New York 10029
| |
Collapse
|
30
|
Abstract
Directional coronary atherectomy (DCA) received Food and Drug Administration (FDA) Pre-Market Approval in September 1990 and was then released through formal training certification of physicians at each new site. Procedure volume has increased dramatically since approval, with > 17,000 DCA procedures performed in 1991 and a cumulative total of > 33,000 procedures by mid-1992, at > 670 centers in the United States. Clinical application and results since approval have generally been similar to preapproval multicenter investigational results. Comparison of pre- and postapproval usage at the Medical College of Virginia shows similar baseline characteristics and indications, although recent patients show a higher proportion of "salvage" DCA for failed or suboptimal angioplasty (6% vs 14%) or DCA in combination with multidevice multiple vessel intervention (30% vs 38%). Overall results in 300 patients and 345 procedures included procedural success in 95%, clinical success in 94%, with major complications in 4.6% (including urgent bypass surgery in 3.8%, Q wave myocardial infarction in 1.7%, and hospital mortality in 0.3%). Results before and after FDA approval were similar for procedural success (94% vs 96%), clinical success rate (94% vs 94%), and major complications (5.5% vs 4.4%). There was a trend toward lower urgent surgery rate (5.4% vs 3.3%) in the more recent experience. In addition to its established efficacy for highly eccentric lesions, newer applications for which DCA is being used following FDA approval include treatment of saphenous vein grafts, thrombus-associated lesions, aorto-ostial lesions, failed or suboptimal percutaneous transluminal coronary angioplasty result, bifurcation lesions, and use as part of multivessel intervention.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- M J Cowley
- Division of Cardiology, Medical College of Virginia, Richmond
| | | |
Collapse
|
31
|
Estella P, Ryan TJ, Landzberg JS, Bittl JA. Excimer laser-assisted coronary angioplasty for lesions containing thrombus. J Am Coll Cardiol 1993; 21:1550-6. [PMID: 8496518 DOI: 10.1016/0735-1097(93)90367-a] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES The purpose of this study was to analyze the success rates for excimer laser-assisted coronary angioplasty performed in patients undergoing angioplasty for lesions containing thrombus. BACKGROUND The presence of intracoronary thrombus increases the risk of a poor clinical outcome after balloon angioplasty. The effect of intracoronary thrombus on the safety and efficacy of excimer laser-assisted coronary angioplasty is unknown. METHODS Percutaneous excimer laser-assisted coronary angioplasty was attempted in 142 patients, of whom 12 had angiographic evidence of intracoronary thrombus in 14 lesions, defined as a filling defect surrounded by contrast medium or an area of contrast staining. RESULTS Clinical success (< 50% residual stenosis without myocardial infarction, death or bypass surgery at any time during hospitalization) was achieved in 7 (58%) of the 12 patients with intracoronary thrombus, compared with 123 (95%) of the 130 patients without thrombus (p = 0.00001). Angiographic and clinical complications were more common in patients with thrombus: embolization (25% vs. 1%, p < 0.001), myocardial infarction (33% vs. 2%, p < 0.001), abrupt closure (17% vs. 4%, p = 0.049). Angiographic restenosis at 6 months was seen at 7 (70%) of 10 treated sites with intracoronary thrombus and at 59 (51%) of 116 sites without thrombus (p = 0.245). Presence of intracoronary thrombus was identified as the most important predictor of clinical success (p = 0.013) by multivariable logistic regression analysis, which controlled for other co-variables, such as lesion complexity or lesion location in a saphenous vein graft. CONCLUSIONS This analysis shows that the success of excimer laser-assisted coronary angioplasty is compromised when thrombus is detected angiographically. Further investigation of other strategies is needed to improve the outcome of angioplasty for this challenging problem.
Collapse
Affiliation(s)
- P Estella
- Department of Medicine, Brigham and women's Hospital, Harvard Medical School, Boston, Massachusetts 02115
| | | | | | | |
Collapse
|
32
|
Topaz O, Rozenbaum EA, Battista S, Peterson C, Wysham DG. Laser facilitated angioplasty and thrombolysis in acute myocardial infarction complicated by prolonged or recurrent chest pain. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1993; 28:7-16; discussion 17. [PMID: 8416336 DOI: 10.1002/ccd.1810280103] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
To date, application of laser angioplasty in acute myocardial infarction (MI) has not been reported. In nine patients with acute myocardial infarction complicated by continuous or recurrent severe ischemia and chest pain, a mid-infrared, solid-state, pulse-wave holmium/thulium:YAG coronary laser was applied. In six of these patients the laser was specifically utilized for the purpose of coronary thrombolysis. In each case a guidewire was placed across the stenosis and a multifiber laser catheter was utilized, emitting 250-600 mJ/pulse at 5 Hz, followed by adjunctive balloon angioplasty. Laser success (defined as ability to cross the lesion, reduction of > or = 20% in stenosis and thrombolysis when a thrombus is present) was achieved in all patients. Final angiograms revealed residual stenosis < or = 30%, adequate thrombolysis and no major complication (MI, perforation, emergency CABGS, CVA, death) in each patient. Clinically, all nine patients improved, survived the acute infarction and were discharged. This initial clinical experience demonstrates the feasibility and safety of holmium/thulium:YAG laser application in thrombolysis and plaque ablation in selected patients who experience acute myocardial infarction complicated by prolonged or recurrent ischemia and chest pain.
Collapse
Affiliation(s)
- O Topaz
- Cardiac Catheterization Laboratories, St. Paul-Ramsey Medical Center, University of Minnesota Medical School 55101
| | | | | | | | | |
Collapse
|