Management of coronary thrombotic lesions

The clinical presentation was a 45-year-old man who presented with an inferior wall STEMI. The patient was treated with chewable aspirin 324 mg, clopidogrel 600 mg, and IV heparin prior to catheterization. Diagnostic angiography revealed extensive thrombus in the RCA with TIMI 1 flow (Fig. 15). A 7 French hockey-stick guide and BMW wires were used for intervention. Eptifibatide infusion was begun together with bivalirudin. A wire was placed in the RPDA after which distal thrombus was seen in the RPLS (Fig. 16). A second BMW was placed in the RPLS and Pronto extraction was performed into the RPDA. After aspiration thrombectomy, thrombus with vessel cutoff was seen in the RPLS and RPDA (Fig. 17). The Pronto was then passed into the RPLS and RPDA. Atropine and neosynephrine were used for supportive measures, and a temporary pacing wire was placed in the right ventricle. Despite multiple passes with the Pronto catheter and delivery of nipride, persistent vessel cutoff was seen in the RPDA and RPLS. Final angiography revealed persistent distal thrombus burden in multiple vessels (Fig. 18). The final intravascular ultrasound (IVUS) revealed no plaque burden in the culprit coronary artery. Further workup revealed a PFO, which was subsequently closed percutaneously.