Multivessel PCI with Thrombus Aspiration During Outpatient Cardiac Catheterization Using a Radial Approach

Patient presentation

A 68-year-old male with diabetes, morbid obesity (BMI-41), hypertension and dyslipidemia presented for an initial cardiovascular evaluation. His other medical history was pertinent for severe chronic obstructive pulmonary disease (COPD) and prior tobacco abuse. He had an episode of moderate chest discomfort two weeks prior to his visit. EKG showed a right bundle branch block with mild T wave inversions. The patient’s medications included insulin, lisinopril, rosuvastatin and multiple inhalers. 

Aspirin and beta blockers were initiated. A Lexiscan nuclear stress test showed a large perfusion defect with significant inferior and inferolateral ischemia, with an ejection fraction of 40%. Cardiac catheterization was recommended due to the patient’s large ischemic burden and decreased left ventricular function. Clopidogrel 600 mg was administered two hours prior to the procedure.

Procedure

A 6 French Glide sheath (Terumo) was used for coronary angiography via the right radial approach. Angiography showed an 80% stenosis in a moderate-sized left circumflex (LCX) artery, and an occluded mid/distal right coronary artery (RCA) with large left to right collaterals. A 70-80% proximal RCA stenosis was also noted. Due to only mild disease in the left anterior descending coronary artery, percutaneous coronary intervention was felt to be appropriate.

Heparin was administered and a 6 French AL1 guide was used to engage the left main. The lesion in the LCX was easily crossed using a balanced middle weight (BMW) wire. 

With the help of intravascular ultrasound, a 3.0 x 12 mm Promus (Boston Scientific) was used to direct stent the LCX lesion. The same AL1 guide was then used to engage the RCA. We had difficulty in crossing the lesion with a BMW wire, but with the help of a 2.0 x 12 mm Maverick balloon (Boston Scientific) for support, we were able to cross the lesion. The balloon was used to dotter (passage of a catheter across a lesion without dilatation) across the stenosis and follow-up angiography showed what initially appeared to be a dissection at the site of the occlusion. However, since the distal wire position appeared intraluminal, we performed a low-pressure inflation of the balloon. Repeat angiography showed a large intraluminal filling defect consistent with thrombus. Eptifibatide was initiated and we performed aspiration thrombectomy with a 6 French Export catheter (Medtronic). A large amount of red thrombotic material was aspirated. At this point, TIMI-3 flow was observed in the vessel. Overlapping 3.0 x 38 mm and 3.0 by 12 mm Promus drug-eluting stents were placed, extending distally from the posterolateral vessel into the mid RCA. The proximal RCA was stented with a 3.5 x 8 mm Promus drug-eluting stent. Hemostasis was obtained using a TR Band (Terumo). The patient was discharged the next day with no complications.

Discussion

This case illustrates the following key points:

1.  Thrombus may be seen during elective outpatient angiography.

In primary PCI for ST-elevation myocardial infarction, thrombus aspiration prior to stent implantation can reduce both the incidence and extent of angioplasty-induced embolization and myocardial necrosis.^1-4 As previously demonstrated, this approach can improve long-term clinical outcome at one-year follow-up.⁵ However, the prevalence of thrombus and the role of aspiration devices in patients without myocardial infarction (MI) is unclear. In a large, retrospective study including almost 5,000 patients undergoing PCI over a 33-month course, thrombus was reported in a small percentage of non-MI patients and these patients accounted for <4% of PCI patients who underwent manual aspiration.⁶ In our patient, we felt the large size of the filling defect justified the use of an aspiration catheter in a ‘non-MI’ setting. Clinicians should be alert to the presence of thrombus even in elective settings.

2. The feasibility of multivessel PCI, including total occlusions, using a radial approach.

This patient was discharged the next day with no access site complications and excellent patient satisfaction. His morbid obesity placed him at high risk for groin-related complications. Compared with the transfemoral approach, the biggest benefit of the transradial technique is the reduction of access site complications. Meta-analyses of smaller trials have suggested reductions in bleeding, as well as trends towards reductions in myocardial ischemic events and death due to these bleeding reductions.⁷ Patients who underwent coronary procedures through the radial artery had a statistically significant reduction in both major and minor bleeding (4.2% vs. 1.96%, P = 0.03) and death or myocardial infarction (3.1% vs. 0.6%, P = 0.005).⁸ This reduction of bleeding was even more dramatic in the sickest patients (e.g., acute myocardial infarctions) and patients who were the most heavily anticoagulated.^9-13 A second benefit from the transradial approach is patient satisfaction. Since patients need not remain flat (as required after femoral access), they tend to have less overall discomfort related to their procedure, and this is reflected in improved satisfaction.^14,15 

Dr. Khanna can be contacted at akhanna@clark-daughtrey.com.

This article received double-blind peer review from members of the Cath Lab Digest Editorial Board.

References

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