Thrombosuction with Export Aspiration Catheter during PCI in Acute MI
Shuvanan Ray1, Bhabani Prasad Chattopadhyay2, Shilanjan Roy3, Subhas Kundu4, P K Deb5, Amal Bannerjee6
Head of the Department of cardiology, A.M.R.I. Hospitals, Salt Lake, Kolkata.
Assistant Professor, Dept. of cardiology, North Bengal Medical College.
Registrar, CCU, A.M.R.I. Salt Lake, Kolkata.
HOD, Cardiology, ESI Hospital, Kolkata
Senior Consultant Cardiologist, Institute of Cardiovascular Sciences, Kolkata.

Introduction:
Primary PCI is now the most effective treatment of occluded coronary artery 1 in AMI. However dilatation of the coronary artery leads to disruption of plaque and stent-deployment results in shifting of plaque. Disruption and shifting of plaque may result in distal embolisation of plaque debris or thrombus. Situation becomes more critical if the infarct related artery is loaded with thrombus.

Slow flow or no-reflow may occur after primary PCI. Reduction of thrombus burden by thrombosuction (with or without distal protection device) in subjects pre-treated with abciximab (Gp IIb-IIIa Inhibitors) can prevent distal embolisation, improve myocardial perfusion and hence myocardial salvage.
Thrombosuction alone unaccompanied by any other additional intervention is infrequently reported2 But thrombosuction may sometimes be all that is required without further need of coronary angioplasty and stenting. The rarity of reported cases of thrombosuction alone merits highlight. Hence the present case is being discussed in the ensuing paragraphs.

Clinical Summary:
A 22 yrs old young man with strongly positive family history of coronary artery disease had inexorable chest pain of one hour duration before he presented to our hospital with diaphoresis, loss of consciousness, feeble pulse (140/min) systolic blood pressure of 70 mm Hg & tachypnoea. Both lungs were full of crepitations and LV – S3 Gallop was present. ECG showed ST elevation in V1 to V4.  Echocardiography revealed gross

was one of the first bare metal stents (BMS) approved in USA.  Subsequently, many more bare metal stents came on the market, but the significant problem of restenosis remained as a major issue. 

In 2003, a drug-eluting stent approved by the Food and Drug Administration (FDA) set another mile stone in reduction of restenosis3.  This therapeutic effect of drug-eluting stent was very impressive with consistently positive reports from subsequent small group trials and first hand experience of the physicians, which led to remarkable adoption of drug-eluting stents, even in patients where there was no approved indications.  This use of drug-eluting stents was termed as an “off-label” use. 

Subsequently in the years 2005 and 2006, many small reports questioned the safety of drug-eluting stents, especially late stent thrombosis.  Some of the studies which prompted media attention included a BASKET-LATE 4 a study presented in the American College of Cardiology in March of 2006, and subsequently a Camenzind’s  meta analysis presented at the European Society of Cardiology in September 2006.  Later, there was also a publication by the SCAAR5 (Swedish Coronary Angiography and Angioplasty registry) registry group from Sweden which got immediate attention of the worldwide interventional community in cardiology.  Their landmark analysis at 6 months showed no difference in mortality among bare metal stents and drug-eluting stents but after 6 months, there was increased mortality in the drug-eluting stent group.  This set off a worldwide panic and Swedish government prohibited the use of drug-eluting stents unless absolutely needed, media calling the drug-eluting stents “a million ticking time bombs”

Correspondence: Dr. Shrivana Ray, Head of the Department of cardiology, A.M.R.I. Hospitals, Salt Lake, Kolkata., West Bengal, India
Email: rk1965@gmail.com

After angiographic visualization LMCA was engaged with a 7F extra backup(XB) guide catheter Over the PTCA guide wire the Export Aspiration  thrombosuction Catheter (Figure 2)  was positioned in the ostium of LAD and with maintained negative suction this was advanced distally. After  thrombosuction LAD was cleared of any visible thrombus and TIMI – III blood flow was achieved (Figure 3). No stenosis was seen after thrombosuction. Stenting was not required.

Post-Procedure Course in the Hospital:
After Cath-Lab procedure  the patient was shifted back to coronary care unit. Intravenous abciximab was continued for next 12 hours. With supportive treatments patient was stabilized, gradually he was weaned off from ventilator & IABP support over next four days. ECG after thrombosuction showed ST segment depression in V1 – V4 with restoration of normal sinus rhythm.

Patient was a  non diabetic, normotensive, non smoker. His serum homocysteine level was 46μmol/litre. Blood levels of protein C, protein S, anti-thrombin III, factor V, factor VIII, vWF, fibrinogen, lupus anticoagulant were all within normal limits.

Follow-up Coronary Angiography:
Coronary angiography was repeated (Figure4)after one and a half months which showed absolutely normal coronaries