Manual Thrombus Aspiration Research Articles

Association of Neutrophil extracellular traps burden with clinical and angiographic characteristics in patients with ST-elevation myocardial infarction

Abstract Background The precise triggers for arterial plaque rupture and the underlying pathophysiology of thrombogenesis remain elusive. Polymorphonuclear neutrophils (PMN), particularly their formation of Neutrophil Extracellular Traps (NETs), have garnered attention in the context of coronary atherothrombosis. This study sought to explore the association of NETs burden with clinical and angiographic characteristics in ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI) and thrombus aspiration (TA). Methods This study included 336 consecutive STEMI patients undergoing pPCI and TA. Aspirated thrombi underwent histological analysis and NETs quantification via immunohistochemistry. Potential associations of clinical variables and angiographic outcomes with NETs burden were assessed. Results Manual TA was selectively performed in 72 cases with increased thrombotic burden and 60 thrombi were suitable for analysis. Most thrombi specimens displayed lytic features (63%) and almost three out of four specimens were identified as white thrombi. Increased NETs burden was significantly associated with prolonged pain-to-balloon time (>300 minutes) OR=10.29 (95% CI 2.11-42.22, p=0.001) and stress-induced hyperglycemia (SIH) OR=6.58 (95% CI 1.23-52.63, p=0.04) after multivariate regression analysis. Additionally, distal embolization (DE), a predictor of adverse outcomes, was more frequent among patients with an elevated NETs burden OR=16.9 (95% CI 4.23-44.52, p<0.001). Conversely, no significant association between NETs burden and final TIMI flow=3 was observed. Conclusion Elevated NETs burden in STEMI thrombi is linked to delayed reperfusion, SIH and increased risk of DE. Further research is needed to elucidate the role of NETs as a potential therapeutic target in acute atherothrombosis.

Impact of thrombus aspiration on left ventricular remodeling and function in patients with ST-segment elevation myocardial infarction: A meta-analysis of randomized controlled trials

BackgroundRoutine thrombus aspiration (TA) does not improve clinical outcomes in patients with ST-segment-elevation myocardial infarction (STEMI), although data from meta-analyses suggest that patients with high thrombus burden may benefit from it. The impact of TA on left ventricular (LV) functional recovery and remodeling after STEMI remains controversial. We aimed to pool data from randomized controlled trials (RCTs) on the impact of TA on LV function and remodeling after primary percutaneous coronary intervention (pPCI). MethodsPubMed and CENTRAL databases were scanned for eligible studies. Primary outcome measures were: LV ejection fraction (LVEF), LV end diastolic volume (LVEDV), LV end systolic volume (LVESV) and wall motion score index (WMSI). A primary pre-specified subgroup analysis was performed comparing manual TA with mechanical TA. ResultsA total of 28 studies enrolling 4990 patients were included. WMSI was lower in TA group than in control (mean difference [MD] -0.11, 95% confidence interval [CI] -0.19 to −0.03). A greater LVEF (MD 1.91, 95% CI 0.76 to 3) and a smaller LVESV (MD -6.19, 95% CI -8.7 to −3.6) were observed in manual TA group compared to control. Meta regressions including patients with left anterior descending artery (LAD) involvement showed an association between TA use and the reduction of both LVEDV and LVESV (z = −2.13, p = 0.03; z = −3.7, p < 0.01) and the improvement in myocardial salvage index (z = 2.04, p = 0.04). ConclusionTA is associated with improved LV function. TA technique, total ischemic time and LAD involvement appears to influence TA benefit on post-infarction LV remodeling.

Strategy of delayed intervention without stent implantation in myocardial infarction with ST segment elevation caused by massive thrombosis of the infarct-related artery

Aim. TIntroduction. To evaluate in-hospital angiographic and five-year posthospital clinical outcomes of percutaneous intervention strategy without stent implantation with immediate coronary artery stenting technique in STEMI patients with massive coronary thrombosis.Material and methods. The study enrolled 116 patients with primary STEMI myocardial infarction with the signs of massive thrombosis in the lumen of the main epicardial coronary artery with TIMI thrombus grade greater than 3 after antegrade blood flow restoration. In the 1st group of delayed intervention at the primary stage the blood flow was restored by small diameter balloon inflation and/ or manual vacuum thrombus aspiration until stable TIMI grade 3 blood flow was achieved, at control CAG on day 5-6 in 36 people the stent was not implanted due to insignificance of infarct-related coronary artery stenosis (stenosis less than 50% according to QCA). Immediate stent implantation was performed in 78 patients (group 2). The primary endpoint was the incidence of adverse cardiovascular events, including total mortality, recurrent myocardial infarction, repeated revascularization of the infarct-responsive artery. Secondary endpoint: frequency of achieving optimal myocardial perfusion as measured by angiography – TIMI blood flow and Myocardial Blush Grade.Results. The median follow-up period was 47 months. The incidence of the primary end point (MACE) was 15,8% in group 1 and 23,1% in group 2, with no statistically significant difference (p=0,408). Overall mortality (10,5% and 11,7%), the rate of repeat myocardial infarction (2,6% and 5,1%), and the rate of repeat target vessel revascularization (2,6% and 6,4%) were without significant advantage between subgroups. Optimal reperfusion (TIMI-3 and Myocardial Blush Grade 2-3 after primary procedure was achieved in significantly (p=0,02) more patients in group 1 (89%) than in group 2 (69,2%) ST segment resolution ≥70% after intervention was achieved in 87% of cases in group 1 and in 64,1% of cases in group 2 (p=0,011).Conclusion. In STEMI patients with massive coronary thrombosis, the method of delayed percutaneous intervention increases the rate of achieving optimal blood flow and allows avoiding stent implantation in the infarct-related artery in 50% of cases as compared to the method of immediate stenting. Both methods have comparable hospital and five-year clinical risks.

Rationale and Design of a Randomized Controlled Pilot Trial to Assess Stent Retriever Thrombectomy for Thrombus Burden Reduction in Patients with Acute Myocardial Infarction: The RETRIEVE-AMI Study

BackgroundST-elevation myocardial infarction (STEMI) is typically caused by thrombotic occlusion of a coronary artery with subsequent hypoperfusion and myocardial necrosis. In approximately half of patients with STEMI, despite successful restoration of epicardial coronary patency, downstream myocardium perfusion remains impeded. Coronary microvascular injury is one of the key mechanisms behind suboptimal myocardial perfusion and it is primarily, yet not exclusively, related to distal embolization of atherothrombotic material following recanalization of the culprit artery. Routine manual thrombus-aspiration has failed to show clinical efficacy in this scenario. This could be related with limitations in technology adopted as well as patients' selection. To this end, we set out to explore the efficacy and safety of stent retriever-assisted thrombectomy based on clot-removal device routinely used in stroke intervention. Study design and objectivesThe stent RETRIEVEr thrombectomy for thrombus burden reduction in patients with Acute Myocardial Infarction (RETRIEVE-AMI) study has been designed to establish whether stent retriever-based thrombectomy is safe and more efficacious in thrombus modification than the current standard of care: manual thrombus aspiration or stenting. The RETRIEVE-AMI trial will enrol 81 participants admitted for primary PCI for inferior STEMI. Participants will be 1:1:1 randomised to receive either standalone PCI, thrombus aspiration and PCI, or retriever-based thrombectomy and PCI. Change in thrombus burden will be assessed via optical coherence tomography imaging. A telephone follow-up at 6 months will be arranged. ConclusionsIt is anticipated by the investigators that stent retriever thrombectomy will more effectively reduce the thrombotic burden compared to current standard of care whilst being clinically safe.

Comparison of Angiographic and in Hospital Outcomes of Thrombuster Versus Pre Ballooning in Primary Percutaneous Coronary Intervention

Introduction: South Asian communities vary from western cultures in terms of their genetic make-up, culture, and predisposition to develop coronary artery disease (CAD). Percutaneous coronary intervention (PCI) has shown remarkable effectiveness over the last three decades. To decrease hospital outcomes, thrombus aspiration and pre ballooning are often employed during angiography. Objectives: To evaluate the angiographic and hospital results between PCI using a thrombuster and PCI using pre-ballooning. Methodology: This research was conducted at Hayatabad Medical Complex, Peshawar from March 2022 to September 2022. 188 patients who came in for primary PCI at the catheterization lab were included and divided into two groups: the “thrombuster group (n=96)”and the “balloon group (n=92)”. In the thrombuster group, manual thrombus aspiration was carried out with the use of a thrombuster, whereas in the balloon group, patients had primary PCI with customary pre-dilatation using a balloon and had their TIMI flow evaluated and graded again. Throughout their hospital stays, all patients were monitored, and study outcomes, such as death and post-procedure problems, were noted. The statistical study made use of SPSS (v.25), and p value less than 0.05 was established as the threshold for significant. Results: 54 participants (26.72%) were women and 134 (71.72%) were men. A statistical study reveals a significant relationship (p=0.027) between gender. With a larger percentage of male patients (36.70%), the balloon group's demographics (n=92; 48.93%) differed from those of the thrombuster group (n=96; 51.06%). In balloon groups, a greater mean age (56.89 10.3) was discovered. With the exception of smoking, all clinical risk factors were greater in balloon groups than in thrombuster patients [17 (9.04%) vs. 12 (6.38%); p=0.007]. When compared to the balloon group (7/92), the Thrombuster groups' in-hospital mortality rate was much lower (2/96). Overall complications were also substantially greater with balloon than with thrombuster. Conclusion: Thrombus aspiration rather than ballooning should be performed using a large lumen guiding catheter in a deep-seated position. Keywords: angiography, coronary artery disease, thromboses, ballooning, angiography

Manual thrombus aspiration during percutaneous coronary intervention: Cherish as “Blessing of Thanksgiving” in a case of spontaneous coronary artery dissection presenting with large intracoronary thrombus burden

Manual thrombus aspiration during percutaneous coronary intervention: Cherish as “Blessing of Thanksgiving” in a case of spontaneous coronary artery dissection presenting with large intracoronary thrombus burden

Benefits of excimer laser coronary angioplasty over thrombus aspiration therapy for patients with acute coronary syndrome and thrombolysis in myocardial infarction flow grade 0.

In primary percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS), the presence of a thrombus or unstable plaque can cause microvascular obstructions, which may increase infarct size and reduce survival. Excimer laser coronary angioplasty (ELCA) is a unique revascularization technique that can vaporize plaques and thrombi. However, to date, only few reports indicate the efficacy of ELCA for ACS. We retrospectively analyzed 113 consecutive ACS patients who underwent PCI with either ELCA or manual thrombus aspiration therapy (TA) before balloon angioplasty or stenting and who had a Thrombolysis in Myocardial Infarction flow (TIMI) grade 0 on the first contrast injection within 24h of onset at our hospital from March 2011 to March 2020. Patients were divided into two groups by the procedure used: ELCA (N = 48) and TA (N = 50). Door-to-reperfusion time was significantly shorter in the ELCA group than TA group (89.2 ± 6.7 vs. 137.9 ± 12.3min, respectively; P < 0.01). There was also a significant difference in peak creatine kinase-myocardial band between the ELCA and TA groups (242 ± 25 vs. 384 ± 63IU/L, respectively; P = 0.04). Although there was no difference in myocardial blush grade (MBG) before treatment, the MBG after treatment was higher in the ELCA group (P < 0.01). In-hospital major adverse cardiac events (MACE) were also significantly fewer in the ELCA group than in the TA group (8% vs. 20%, P = 0.045). ELCA for TIMI grade 0 ACS may shorten reperfusion time, improve the MBG score, and reduce MACE when compared to TA.

279 LAYERED PLAQUES: NOT ALL ARE HEALED

Abstract Layered plaques are the effect of a previous plaque event. They are associated with coronary spasm and found in more than 50% of patients with stable angina and a quarter of those with an acute coronary syndrome. Nevertheless, it is not clear whether their presence is indicative of a healing process or rather is predictive of an increased risk of future events. A 71-year-old male, heavy smoker and hypertensive, presented with episodes of angina at rest that resolved spontaneously in less than 5 minutes, with evidence of ST-segment elevation (STE) in the lower leads during one of these episodes. Coronary angiography showed an intermediate stenosis at the end of the mid segment of the dominant right coronary artery (RCA) (Figure A). Optical coherence tomography (OCT) revealed a layered plaque, consisting of high backscattering layers alternated with low reflection layers (Figures A1-3). Given the minimum luminal area of 3.65 mm2 and the absence of other criteria for plaque instability (erosion, thin-cap, etc.), we treated the patient conservatively with medical therapy alone, consisting of a single antiplatelet agent and a high-dose statin with ezetimibe. A non-dihydropyridine calcium antagonist and a long-acting nitrate were started given the suspicion of coronary spasm. Four months later the patient returned to the emergency department for persistent oppressive chest pain unresponsive to sublingual nitrates with evidence of STE in the lower leads. Emergency coronary angiography showed an acute occlusion of RCA with TIMI 0 flow in correspondence to the layered plaque highlighted 4 months earlier on OCT (Figure B). Antegrade flow was restored with manual thrombus aspiration (Figure C) and OCT showed lesion progression with many new layers, together with a cavity suggestive of plaque rupture (Figures C1-3). A 3.5×38 mm everolimus eluting stent was deployed – based on OCT sizing – and post-dilated with a 4.0×8 mm non-compliant balloon, obtaining an excellent angiographic result with TIMI 3 flow (Figure D). Low-reflecting layers within layered plaques are generally considered to be lipid deposits, but they could also represent intraplaque haemorrhages, generated by coronary spasm. The haematoma can be reorganised within the plaque to create a new layer, leading to lesion progression without necessarily requiring a loss of endothelial integrity. The progressive increase of the haematoma may lead to plaque rupture when the pressure exceeds the resistance of superficial layers. This case reveals a new possible mechanism of plaque progression in patients with coronary spasm and explains how layered plaques can be ambivalently considered to be either stable or vulnerable. Their treatment should be meticulously tailored not only based on classical criteria of plaque instability but also according to the underlying trigger mechanism.

429 KOUNIS-ZAVRAS SYNDROME: UNDERREPRESENTED OR UNDERDIAGNOSED?

Abstract A 64-year-old man was admitted to the emergency department for a major allergic reaction to an insect bite. On physical examination, he presented with tachycardia, hypotension and diffuse pomphoid erythema requiring treatment with intravenous cortisone and antihistamines, with partial benefit. From his past medical history hypertension and previous percutaneous coronary intervention (PCI) with drug eluting stents (DES) on left anterior descendant (LAD) and circumflex coronary artery (Cx) for stable angina emerged. Almost 15 minutes after his admission he developed oppressive chest pain and dyspnea, so an electrocardiogram (EKG) was performed showing an ST segment elevation in inferior-posterior-lateral leads. Therefore, the patient was transferred to the Cath Lab to perform a coronary angiography study with finding of intrastent thrombosis (IST) of Cx and LAD and sub-occlusion of the posterior interventricular branch of the right coronary artery (RCA), not responsive to nitrates. PCI was performed with manual thrombus aspiration and high pressure non-compliant balloons of the IST and PCI with a single DES of the RCA lesion. The patient was then transferred to coronary intensive care unit. Echocardiography revealed a normal left ventricle ejection fraction without any wall motion abnormalities and the EKG showed a complete ST resolution. Laboratory exams showed increased troponin, typical of myocardial infarction, and an increase in IgE and serum tryptase, typical for an allergic reaction. Based on clinical, angiographic and biochemical data, diagnosis of type III Kounis-Zavras (KS) syndrome was made. KS is an acute coronary event in the setting of a hypersensitivity reaction which trigger the release of inflammatory mediators by activated mast cell leading to coronary artery spasm, atheromatous plaque rupture or stent thrombosis. Optimal medical therapy for both ischemic heart disease and allergic reaction was set, with ace inhibitor, high dose statin, non-dihydropyridine calcium channel blocker, dual antiplatelet therapy, antihistamines and cortisone with a decalage scheme. There is no consensus for KS management and the difficulty lies in the fact that treating one of the two concomitant conditions could worsen the other. Three variants of this syndrome have been described in the literature. Type I KS is characterized by coronary spasm in patients typically lacking cardiovascular risk factors and coronary arteries free from atheromatous lesions. Type II KS is characterized by instability of an already present coronary plaque. Type III KS is characterized by intrastent thrombosis in patients with previous coronary angioplasty. Several factors incriminated in KS syndrome have been described, including medications (such as antibiotics, analgesics and anti-inflammatories) and environmental factors (such as, bee sting, viper venom, wasp sting). The underlying pathophysiological process involves a series of mediators, such as histamine and tryptase, released by activated mast cells locally during an immunological reaction. KS syndrome is a real challenge since there is no definitive guidelines for diagnosis, management and treatment and the plethora of clinical presentation range from angina pectoris with mild atopic dermatitis to acute coronary syndrome with cardiogenic shock and anaphylaxis. This broad spectrum of clinical manifestations associated with the increasing new triggers (drugs, contrast dye, insects) often leads to a misdiagnosis with a delay of the proper administration of the effective therapy, sometimes resulting fatal.

532 SEX-RELATED DIFFERENCES IN THROMBUS BURDEN IN ST-ELEVATION MYOCARDIAL INFARCTION PATIENTS UNDERGOING PRIMARY PERCUTANEOUS CORONARY INTERVENTION

Abstract Background Women have a worse prognosis after ST-segment elevation myocardial infarction (STEMI) than men. The prognostic role of thrombus burden (TB) in influencing the sex-related differences in clinical outcomes after STEMI has not been clearly investigated. Objectives The aim of this study was to assess the sex-related differences in TB and its clinical implication in patients with STEMI. Methods We analyzed individual patient data from the 3 major randomized clinical trials of manual thrombus aspiration, encompassing a total of 19,047 patients with STEMI, of whom 13,885 (76.1%) were men and 4,371 (23.9%) were women. The primary outcome of interest was 1-year cardiovascular (CV) death. The secondary outcomes of interest were recurrent myocardial infarction, heart failure, all-cause mortality, stroke, stent thrombosis (ST), and target vessel revascularization at 1 year. Results Patients with high TB (HTB) had worse 1-year outcomes compared with those presenting with low TB (adjusted HR for CV death; 1.52; 95% CI: 1.10-2.12; P=0.01). In unadjusted analyses, female sex was associated with an increased risk for 1-year CV death regardless of TB. After adjustment, this risk for 1-year CV death was higher only in women with HTB (HR 1.23, 95% CI: 1.18-1.28; P&amp;lt;0.001) who also had an increased risk for all-cause death and ST than men. Conclusion In patients with STEMI, angiographic evidence of HTB negatively affected prognosis. Among patients with HTB, women had an excess risk for stent thrombosis, CV and all-cause mortality than men. Further investigations are warranted to better understand the pathophysiological mechanisms leading to excess mortality in women with STEMI and HTB.

Sex-Related Differences in Thrombus Burden in STEMI Patients Undergoing Primary Percutaneous Coronary Intervention

BackgroundWomen have a worse prognosis after ST-segment elevation myocardial infarction (STEMI) than men. The prognostic role of thrombus burden (TB) in influencing the sex-related differences in clinical outcomes after STEMI has not been clearly investigated. ObjectivesThe aim of this study was to assess the sex-related differences in TB and its clinical implications in patients with STEMI. MethodsIndividual patient data from the 3 major randomized clinical trials of manual thrombus aspiration were analyzed, encompassing a total of 19,047 patients with STEMI, of whom 13,885 (76.1%) were men and 4,371 (23.9%) were women. The primary outcome of interest was 1-year cardiovascular (CV) death. The secondary outcomes of interest were recurrent myocardial infarction, heart failure, all-cause mortality, stroke, stent thrombosis (ST), and target vessel revascularization at 1 year. ResultsPatients with high TB (HTB) had worse 1-year outcomes compared with those presenting with low TB (adjusted HR for CV death: 1.52; 95% CI: 1.10-2.12; P = 0.01). In unadjusted analyses, female sex was associated with an increased risk for 1-year CV death regardless of TB. After adjustment, the risk for 1-year CV death was higher only in women with HTB (HR: 1.23; 95% CI: 1.18-1.28; P < 0.001), who also had an increased risk for all-cause death and ST than men. ConclusionsIn patients with STEMI, angiographic evidence of HTB negatively affected prognosis. Among patients with HTB, women had an excess risk for ST, CV, and all-cause mortality than men. Further investigations are warranted to better understand the pathophysiological mechanisms leading to excess mortality in women with STEMI and HTB.

Outcomes of thrombus aspiration during primary percutaneous coronary intervention for ST-elevation myocardial infarction.

Previous large multi-centre randomised controlled trials have not provided clear benefit with routine intracoronary thrombus aspiration (TA) as an adjunct to primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI). To determine whether there is a difference in outcomes with the use of manual TA prior to PCI, compared with PCI alone in a cohort of patients with STEMI. We analysed data from 6270 consecutive patients undergoing primary PCI for STEMI prospectively enrolled in the Melbourne Interventional Group registry between 2007 and 2018. Multivariable analysis was performed to determine predictors of 30-day major adverse cardiovascular and cerebrovascular events (MACCE) and long-term mortality. We compared 1621 (26%) patients undergoing primary PCI with TA to 4649 (74%) patients undergoing PCI alone. Male gender (81% vs 78%; P < 0.01), younger age (61 vs 63 years; P = 0.03), GP-IIb/IIIa use (76% vs 58%, P < 0.01), and current smoking (40% vs 36%; P < 0.01) were more common in the TA group. TA was more likely to be used in patients with complex lesions (83% vs 66%; P < 0.01) with TIMI 0 flow (77% vs 56%; P < 0.01). No significant difference in post-procedural TIMI flow, stroke, 30-day mortality, or long-term mortality were identified. Multivariable analysis demonstrated a reduction in 30-day MACCE (hazard ratio (HR) 0.75; confidence interval (CI) 0.63-0.89; P < 0.01) in the TA group, but was not associated with long-term mortality (HR 0.98; CI 0.85-1.1; P = 0.73). The use of TA in patients undergoing primary PCI for STEMI was not associated with improved short or long-term mortality when compared with PCI alone.

Thrombus characteristics evaluated by acute optical coherence tomography in ST elevation myocardial Infarction.

ST elevation myocardial infarction (STEMI) is caused by an occlusive thrombosis of a coronary artery. We wanted to assess if the thrombus can be characterized according to erythrocyte content and age using intravascular optical coherence tomography (OCT) in a clinical setting. We performed manual thrombus aspiration in 66 STEMI patients. OCT was done of the thrombus remnants after aspiration. A light intensity ratio was measured through the thrombus. Forty two of the aspirates had thrombus which could be analyzed histomorphologically for analysis of erythrocyte and platelet content, and to determine the age of thrombus as fresh, lytic or organized. There were 11 red, 21 white and 10 mixed thrombi. Furthermore, 36 aspirates had elements of fresh, 7 of lytic and 8 of organized thrombi. There was no correlation between colour and age. OCT appearance could not predict erythrocyte or platelet content. The light intensity ratios were not significantly different in fresh, lytic or organized thrombi. OCT could not differentiate between red and white thrombi, nor determine thrombus age.

AngioJet rheolytic thrombectomy in patients with thrombolysis in myocardial infarction thrombus grade 5: an observational study

The aim of this study was to evaluate the effectiveness and safety of AngioJet rheolytic thrombectomy among patients with high thrombus burden. Routine manual thrombus aspiration in patients with ST-segment elevation myocardial infarction (STEMI) does not improve clinical outcomes and was associated with an increased rate of stroke. However, the safety of mechanical thrombus aspiration is still unknown. This was a retrospective, single-center study involving 621 patients with Thrombolysis In Myocardial Infarction thrombus grade 5. The primary outcome was the composite of major adverse cardiovascular events (MACE) within 12 months. The safety outcome was stroke within 1-year. Propensity matching score was calculated due to the significant baseline differences between the AngioJet rhelytic thrombectomy group and the routine treatment group. AngioJet rheolytic thrombectomy was performed in 117 patients. After propensity-score matching, there was no significant difference both in the incidence of MACE (11.1% vs 17.9%, hazard ratio, 1.641; 95% confidence interval [CI] 0.822 to 3.277, p = 0.161) and the incidences of stroke (1.7% vs 2.6%, hazard ratio 1.522; 95% confidence interval [CI] 0.254 to 9.107, p = 0.646) between two groups at 1-year follow-up. In patients with Thrombolysis In Myocardial Infarction thrombus grade 5, AngioJet rheolytic thrombectomy did not improve clinical outcomes at 1 year. However, AngioJet rheolytic thrombectomy did not increase the risk of stroke in patients with high thrombus burden.

Clinical effectiveness of thrombus aspiration during percutaneous coronary intervention for stent thrombosis in a contemporary setting

ObjectiveThe impact of adjunctive manual thrombus aspiration (TA) in patients with stent thrombosis (ST) treated with percutaneous intervention has not been evaluated in the current era of potent P2Y12 agents and new-generation drug-eluting stents. We sought to assess the effect of TA using data from a large contemporary registry. MethodsThe study population was derived from the Essex ST Investigation Registry (ESTHIR), which contains all consecutive cases of angiographically determined definite ST undergoing interventional treatment in a tertiary cardiac centre between November 2015 and June 2018. Propensity score matching was performed to match patients who underwent TA (TA group) to those who did not (n-TA group). The study endpoints were final TIMI flow and survival free of cardiovascular death (CD) or target lesion revascularisation (TLR). ResultsA total of 128 ST patients were included in the present analysis. The mean age was 65 ± 11 years, and 84% were male. About 90% of the patients presented with STEMI, and 85% had very late ST. Seventy-two patients (56%) underwent TA. After propensity score matching, 30 patients were included in each study group. A higher rate of final TIMI III flow was observed in the TA group (TA vs n-TA group, 100% vs 83%), but this difference did not reach statistical significance (p = 0.052). At 1000 days of follow-up, survival free of CD or TLR was not different between the two groups (p = 0.8). ConclusionIn a propensity-matched population of ST patients undergoing PCI in a contemporary setting, TA was not associated with improved final TIMI flow or long-term cardiovascular outcomes.

Sudden Death in a Young Male Patient: When Lupus and Cardiovascular Disease Intersect

Herein we present the case of a 27-year-old male patient who was recently diagnosed with Systemic Lupus Erythematosus (SLE) associated with nephritis with atypical findings on kidney biopsy and premature cardiovascular disease despite scarce traditional risk factors and negative laboratory findings for antiphospholipid syndrome. A literature review on the epidemiology and pathogenesis of coronary disease in SLE was conducted. The patient was admitted for pulse therapy after refractory disease on outpatient care but evolved with ventricular fibrillation secondary to acute thrombosis in the proximal segment of the anterior left descending artery, with no evidence of atherosclerotic disease. Laboratory findings were also negative for antiphospholipid syndrome both upon diagnosis and after the coronary event. He underwent manual thrombus aspiration and angioplasty with a drug-eluting stent, successfully weaning off mechanical ventilation and vasopressors at the intensive care unit and showing no neurological deficits or left ventricular function impairment. Kidney biopsy later resulted positive for immunoglobulin A nephropathy. The patient was discharged asymptomatic on guideline-directed therapy for coronary disease, warfarin associated with clopidogrel, anti-hypertensive drugs and a combination of immunosuppressants, remaining well on three-month follow-up. SLE is a chronic inflammatory disease that has increasingly been recognized as a major cardiovascular risk factor due to a variety of mechanisms involving accelerated atherosclerosis and thrombosis. As patients survive the first years of disease onset from infection and disease-specific complications, cardiovascular outcomes become a great concern. However, early events such as in this case are possible, especially in the context of flaring disease. We emphasize the importance of an interdisciplinary approach to such patients for better outcomes.

Thrombus aspiration during primary percutaneous coronary intervention: Which patients? An observational prospective study

Since the 2000s, thrombus aspiration (TA) has been widely used in the percutaneous coronary intervention (PCI) of ST elevated myocardial infarction (STEMI). Otherwise, recent trials have questioned its safety. Therefore, guidelines are against the routine use of manual TA during primary PCI. Our study aimed to evaluate the immediate angiographic results of the TA to assess the predictive factors of its failure. An observational prospective study was performed from 2016 to 2018. We included all patients who underwent TA using the ExportTM catheter during a primary PCI for less than 12 h of STEMI. The primary endpoint was the failure of TA assessed by TIMI classification for the final coronary flow. Insufficient reperfusion due to failed TA was defined as a TIMI flow < 3 in the culprit artery at the end of the PCI. The secondary composite endpoint was the occurrence of in-hospital Major Adverse CerebroCardiovascular Events (MACCE). We have included 60 consecutive patients. Mean age was 59.7 ± 13.6 years. 81.7% were males. Anterior location of STEMI was noted in 60%. The median delay between symptoms and wire crossing was 5 [3.8-8.7] hours. Initially, 68.3% of the patients presented a TIMI 0 flow and final TIMI 3 flow was established in 66.7% of cases. We identified 4 patients with in-hospital MACCE. Our results suggest a high rate of angiographic failure(33.3%) following a primary PCI despite the use of TA. The associate factors of a failure TA were: the delay between symptoms onset and wire crossing ≥ 5h( P = 0.025) and a cardiogenic shock( P = 0.04). The multivariate study showed that tardive presentation (> 5 h) was the only predictive factor of a failed TA HR = 4 [1.1-14], P = 0.037. Despite the limitation of our observational study, we noted an important rate of slow and no flow in the setting of primary PCI despite using TA. Identifying such risk factors will improve the effectiveness of the primary PCI with a selective TA.

Submassive pulmonary thromboembolism, post-COVID sequelae; with mechanical thrombus aspiration and accelerated thrombolysis by Ekos ultrasound with successful resolution

IntroductionAcute pulmonary thromboembolism is a pulmonary pathology that is becoming more frequent nowadays, the use of new mechanical and thrombolytic therapies has a significant impact on the cardiopulmonary prognosis.CaseA 41-year-old male, a retired military man, smoking, overweight, dyslipidemia, alcoholic liver disease, who attended the emergency department due to abrupt dyspnea, with tachycardia, chest pain, and syncope; the patient had tachycardia of 120 bpm, BP 90/60 mmHg and SO2 of 82%, with a history of COVID-19 infection, suspected of massive pulmonary embolism, it was decided to carry out computed tomography where a bilateral submassive pulmonary embolism was documented (Fig. 1A), it was proposed to perform systemic thrombolysis, however due to the risk of bleeding, it was decided to perform EKOS ultrasound directed thrombolysis. Baseline pulmonary angiography was performed with a large number of thrombi (Fig. 1B), distributed in both main right and left branches and deficient pulmonary filling of distal vessels, due to the large amount of thrombus, it was decided to perform manual thrombus aspiration, obtaining a large amount of thrombus (Fig. 1C), as well as thrombolysis in situ with Alteplase a dose of 1 mg/catheter/hour for 12 hours, with a total dose of 24 mg; Ultrasound probe was placed in both pulmonary arteries with the EKOS system (Fig. 1D).ResultsPulmonary angiography was performed 24 hours after the procedure, where no bleeding occurred and almost complete resolution of the thrombus was observed. The patient later with 92% SO2, without oxygen requirements, with HR 90 bpm, with no evidence of ventricular dysfunction, was discharged home with anticoagulation.ConclusionLow dose fibrinolysis and thromboaspiration are considered, as well as the use of EKOS endovascular ultrasound, a safe and effective procedure, in the context of a patient with high-risk of bleeding, with favorable results that condition clinical and prognostic improvement.

Abstract 13716: Significance of Time in Use of Manual Thrombus Aspiration in Patients Undergoing Primary PCI for Achieving TIMI 3 Flow

Background: Primary percutaneous intervention is a life-saving procedure to open the occluded coronary artery. Most of these patients have either total occlusion of artery or have high thrombus burden.Therefore, timely use of thrombus aspiration catheters have a significant importance in terms of morbidity and mortality. Purpose: To assess the effect of timing of manual thrombus aspiration in patients undergoing Primary PCI on post procedure TIMI 3 Flow and in hospital outcomes of a tertiary care hospital. Methods: In this prospective observational study, patients with acute STEMI who underwent primary PCI and have totally occluded coronary artery (TIMI 0 flow) after passing the wire were selected. Time from the onset of chest pain to the use of export catheters (Export time) was calculated in these patients and subsequently in-hospital outcome was monitored. Results: 251 patients were enrolled Cut off value for optimal timing of thrombus aspiration was determined to be 315 minutes with a sensitivity of 68% and specificity of 50%. 117 patients reached in 315 minutes in which Export was used, they achieved post procedure TIMI III flow in 87.2% of patients and 75.4% in which Export was used after 315 minutes. Conclusion: Export time is a significant parameter that achieved better coronary intervention results in terms of post procedure TIMI III flow with the short Export time. Therefore, timely thrombus aspiration should be done for the maximum benefit.

Manual Thrombus Aspiration and its Procedural Stroke Risk in Myocardial Infarction.

BackgroundThe previous large‐scale randomized controlled trial showed that routine thrombus aspiration (TA) during percutaneous coronary intervention (PCI) was associated with an increased risk of stroke. However, real‐world clinical evidence is still limited.Methods and ResultsWe investigated the association between manual TA and stroke risk during primary PCI in the OACIS (Osaka Acute Coronary Insufficiency Study) database (N=12 093). The OACIS is a prospective, multicenter registry of myocardial infarction. The primary end point of the present study is stroke at 7 days. A total of 9147 patients who underwent primary PCI within 24 hours of hospitalization were finally analyzed (TA group, n=4448, versus non‐TA group, n=4699 patients). TA was independently associated with risk of stroke at 7 days (odds ratio [OR], 1.92 [95% CI, 1.19‒3.12]; P=0.008) in the simple logistic regression model, while the multilevel random effects logistic regression model with hospital treated as a random effect showed that manual TA was not associated with incremental risk of stroke at 7 days (OR, 0.91 [95% CI, 0.71‒1.16]; P=0.435). The 7‐day stroke risk of manual TA was significantly heterogeneous in different institutions (P for interaction=0.007).ConclusionsManual TA during primary PCI for patients with acute myocardial infarction was independently associated with the overall increased risk of periprocedural stroke. However, this result was substantially skewed because of institution specific risk variation, suggesting that the periprocedural stroke may be preventable by prudent PCI procedure or appropriate periprocedural management.RegistrationURL: https://upload.umin.ac.jp/cgi‐open‐bin/ctr_e/ctr_view.cgi?recptno=R000005464. Unique identifier: UMIN000004575.