How to manage a large intracorory thrombus in case of ongoing ischemia

Operators:Manos Brilakis
Peter Tatji
discussant: Mutlu Vural

Mineopolis Heart Institude

How to approach large intracoronary thrombus is unclear. With Manos Brilakis’s permission, his demontrative case shared here which has invaluable messeages (Video 1). Unfortunately, thrombectomy catheter didn’t work in this case. Probably because his mouth was wider, the guide catheter extension was used to remove thrombus, but it didn’t work either. Normally he tried to pull the thrombus into the catheter using a filter like a basket, which normally remains in the distal position, but it failed as well. In the meantime, distal embolism and total occlusion developed. When the clinical condition deteriorated, the left ventricular assist device was used. If partial antegrade current is present, he concluded that a large intracoronary thrombus can be followed conservatively even in the presence of ongoing ischemia. Can it be more accurate to show a conservative approach than the one proposed in the algorithm? Shouldn’t we step on the snake’s tail?

In this case, drug treatment options need to be discussed.

But what could be the reason for the failure to remove the thrombus?

Here, the natural curvature of the artery probably pushes the thrombectomy catheter to the lateral wall ( Figure 1), exactly according to the current physiology. The thrombus is accumulated medially from where the flow was slow.

What other thrombectomy option would be?

The Fogarty catheter used in the periphery was useless ( Figure 2). The ascending aorta would be the place where the thrombus would be discharged and would cause other new problems?

What new technology can develop?

Can the technique used in acute stroke ( Figure 3) be used with modified bigger devices for special coronary thrombus?

What do you say?


Video 1

Figure 1

Figure 2

Figure 3

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Original Techniques