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TCTAP C-015

Large Thrombus Burden Management

By Sheng-Fu Liu, Hsien-Li Kao

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Presenter

Sheng-Fu Liu

Authors

Sheng-Fu Liu¹, Hsien-Li Kao¹

Affiliation

National Taiwan University Hospital, Taiwan¹,

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TCTAP C-015

Coronary - ACS/AMI

Large Thrombus Burden Management

Sheng-Fu Liu¹, Hsien-Li Kao¹

National Taiwan University Hospital, Taiwan¹,

Clinical Information

Patient initials or Identifier Number

Relevant Clinical History and Physical Exam

57 year old gentleman was a case of active smoker and chronic obstructive pulmonary disease. He presented acute 57chest pain at night and visited emergency department for help. Initial vital signs showed BT 34.9 celsius degree, HR 57 beats/min, RR 20/min, BP 84/69mmHg, SpO2 98%.
PE revealed compression chest pain with diaphoresis and basal rales.

Relevant Test Results Prior to Catheterization

Chest X ray: Kerley'A line (+), Kerley B's line (+), Cephalization (+), thickening interlobar fisures...etc. All features indicated pulmonary edemaEKG: Complete atrioventricular block

Relevant Catheterization Findings

CAG:LM: patentLAD: non-significant stenosis, milking in dLAD, collateral to RCALCX: non-significant stenosisRCA: 80% stenosis in pRCA with large thrombus burden

Interventional Management

Procedural Step

1. do RFA and RFV puncture and set TPM to RV apex2. engage to RCA with GC 7F JR43. wiring to dRCA with Sion but failed and rewiring with Fielder FC successfully4. perform thrombosuction with 7Fr MERIT aspiration catheter and red thrombi was aspirated5. much thrombi is noted with hypotension6. give Levophed IF and Aggrastat 850mcg ic7. perform thrombosuction with 7Fr MERIT aspiration catheter and red thrombi was aspirated8. persisted hypotension9. give Gipamin IF10. perform thrombosuction with 7Fr MERIT aspiration catheter and no red thrombi aspirated due to large thrombi. There is still much thrombi at mRCA and dRCA.11. POBA to pRCA with BC 3.0, c/w no reflow in dRCA12. perform thrombosuction with 7Fr MERIT aspiration catheter and red thrombi was aspirated. The flow was recoveried.13. give Urokinase 60000u ic for large burden of thrombi14. perform thrombosuction with 7Fr MERIT aspiration catheter and red thrombi was aspirated15. give Urokinase 60000u ic for large burden of thrombi. The burden of thrombi became smaller and fragmented16. POBA to pRCA with BC 4.017. POBAS to pRCA with BMS "Multi-link 4.0x18mm"18. post dilatation to pRCA stent with stent balloon and NC 4.519. post dilatation to pRCA stent edge with NC 5.020. final result is good, up to TIMI 3 flow21. implant IABP for cardiac support due to cardiogenic shock

Case Summary

Large thrombus burden often cause intervention faliure in STEMI patients. Intracoronary administration of Urokinase during primary PCI effectively improved myocardial perfusion in STEMI with cardiogenic shock pateints.

E-Case

TCTAP C-015