Guide Catheter Suction with Novel Double Wire Technique for Successful Management of Large Thrombus in Occluded Right Coronary Artery

Abstract: Patients with large intracoronary thrombi represent a difficult management problem for the interventional cardiologist. Deep guide catheter engagement and thrombus aspiration have been described but are associated with serious risk of dissection and vessel closure. We describe here thrombus aspiration using a guide catheter with novel double wire technique to achieve rapid reperfusion of the coronary artery while avoiding possible complications associated with the technique.

J INVASIVE CARDIOL 2012;24:141–143

Key words: guide catheter suction, coronary angioplasty, thrombosuction

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Thrombus laden coronary artery lesions present a particular challenge to the interventional cardiologist. Despite the development of multiple pharmacologic strategies and mechanical devices to tackle this problem, lesions with angiographically visible thrombus still carry a high risk of complications when coronary intervention is attempted.¹ We present a case of acute ST-elevation inferior myocardial infarction (STEMI) with a large thrombus burden in the right coronary artery that did not yield to thrombus aspiration devices and pharmacologic regimen. Therefore, modified technique of guide catheter aspiration was used to achieve rapid reperfusion of the infarct related artery.

Case report

A 60-year-old man with past medical history of diabetes and a current smoker presented to our hospital with complaint of sudden onset chest pain of 4 H duration associated with diaphoresis. His ECG showed acute ST-elevation inferior wall myocardial infarction. Clinical examination revealed a systolic blood pressure of 80 mm Hg.  In view of ongoing chest pain and the patient being in hypotension, patient was taken up for primary percutaneous intervention. He was pretreated with aspirin (350 mg of dispersible tablet) and prasugrel (60 mg), and glycoprotein IIb/IIIa was started. Coronary angiography showed a normal left coronary system and proximal thrombotic occlusion of dominant right coronary artery (RCA) (Figure 1). RCA was engaged with 7 Fr Judkins right guide catheter (Medtronic Vascular) and the lesion was crossed with a stabilizer plus wire (Cordis Corporation). For thrombosuction, a 6 Fr Export catheter (Medtronic) was passed into the RCA. However, repeated attempts failed to restore any flow in the artery. In view of the deteriorating condition of the patient and no response to these pharmacologic and mechanical approaches, guide catheter suction was planned.

Another 0.014-inch choice floppy wire (Boston Scientific) was passed across the lesion. The 7 Fr guide catheter was withdrawn and a 5 Fr guide catheter was passed over the choice floppy wire (Figure 2), which was slowly intubated deep into the mid segment of the RCA (Figure 3).  The choice floppy wire was then withdrawn while the stabilizer plus wire was kept in the artery. The hub of the guide catheter was disconnected from the Y-connector and a 20 mL Luer-Lok syringe (Becton-Dickinson) was attached. Maintaining a constant and moderate negative suction, the guide catheter was slowly withdrawn from the artery and out of the femoral sheath. Flushing of the guide catheter revealed chunks of intact thrombus that matched the filling defect (Figure 4). While all this was done, the stabilizer wire was in the RCA to ensure access to the distal RCA. There was significant improvement in blood pressure of the patient along with relief in the chest pain. A 7 Fr guide catheter was passed over the stabilizer wire and the RCA was engaged (Figure 5). Angiogram revealed a widely patent artery with TIMI III flow and a residual stenosis of 80% in mid segment of the RCA (Figure 6). The lesion was stented with a non-drug-eluting Prokinetic stent 4 mm x18 mm (Biotronik AG). Post-dilatation, patient developed slow flow, which was successfully managed. Final angiogram showed a well-expanded stent with TIMI III flow (Figure 7). Post-procedure hospital course of the patient was uncomplicated and he was discharged on dual antiplatelet regimen on day 4.

Discussion

Thrombotic occlusion of coronary artery with angiographically visible thrombus in primary percutaneous intervention predicts both increased risk of distal embolization and increased periprocedural complications.² The challenges and procedural risks are particularly great when thrombus burden is large or thrombus present in a threatening position. Presently available regimes for dealing with thrombus aim to extract thrombus and prevent distal embolization, and slow and no flow phenomenon. Treatment strategies that have been used to deal with thrombus include pharmacologic strategies like intracoronary lytic infusions and mechanical approaches like ultrasound frequency, rheolytic thrombectomy, thrombosuction catheters, and guide catheter suction.^3-7 Strategies to prevent slow and no flow phenomenon include adjunctive pharmacotherapy such as the use of glycoprotein GP IIb/IIIa inhibitors and various intracoronary vasodilators (verapamil, glyceryl trinitrate, nitroprusside, adenosine and combination of atropine and diltiazem).⁸

In this case, thrombus burden in RCA was large and patient was in shock. Even after adjunctive pharmacotherapy and optimal use of thrombosuction catheter, flow in right coronary artery could not be restored. In such a setting, we were left with the option of thrombosuction using the guide catheter. Such guide catheter aspiration is associated with serious complications like guide-induced endothelial injury and/or vessel dissection and often collapse of distal vessel.^1,9 We therefore used a simple novel double wire technique to avoid these complications and achieve successful reperfusion. The lesion was crossed with 2 floppy wires. After initial angiogram with 7 Fr guide catheter and failure to achieve reperfusion with aspiration catheters, this guide catheter was exchanged over the 0.014-inch floppy wire with a 5 Fr guide catheter. This catheter was then deeply intubated up to mid RCA. One 0.014” wire was then withdrawn. Now the occluded RCA had an intubated 5 Fr guide catheter for thrombosuction and a 0.014-inch floppy wire going by the side of guide catheter up to distal RCA. The guide catheter was now withdrawn gradually into the aorta and then out of femoral sheath with continuous suction. While this was being done, one 0.014-inch wire was already in the RCA. This helped in 2 ways. First, even if artery was dissected due to guide, this wire ensured proper access to the distal RCA. Second, after withdrawing 5 Fr guide catheter, new 7 Fr guide was inserted over the existing wire. Hence, there was no need to recross the lesion. Post suction angiogram showed TIMI III flow in the RCA with no thrombus and residual stenosis in mid RCA. This residual stenosis was stented with a non-drug-eluting stent.

Guide aspiration has been frequently described in literature.^1,7,8,9 However, it is believed that this technique should be used only in extreme situations when other approaches for thrombus aspiration fail. Current generation 5 Fr and 6 Fr guides are very useful for extracting large thrombi as their inner lumen is considerably larger than that of dedicated aspiration catheters.⁹ Role of such aspiration is now well established. No current available reports describe any technique to ensure proper access to the distal coronary bed in case complications like vessel dissection and collapse occurrences due to guide catheter aspiration. This 2-wire technique is a simple and novel way to maintain access to the distal vasculature of the occluded artery while the guide can be safely intubated deep into the coronary artery depending upon the thrombus burden. Even if the dissection occurs or the distal vessel collapses, presence of a wire in the coronary artery will ensure prompt and true access to the lumen of the coronary artery.

This case demonstrates that with a suitable anatomy, judicious and cautious use of guide catheter suction with double wire in situ might help in rapid restoration of circulation in the occluded artery with large thrombus burden while avoiding life-threatening complications associated with this procedure. This technique ensures the efficacy of the guide catheter suction while maintaining the safety by avoiding possible complications associated with the procedure.

References

1. Pornratanarangsi S, El-Jack SS, Webster MW, et al. Extraction of challenging intracoronary thrombi: multi-device strategies using guide catheters, distal vascular protection devices and aspiration catheters. J Invasive Cardiol. 2008 Sep;20(9):455-462.
2. Mabin TA, Holmes DR Jr, Smith HC, et al. Intracoronary thrombus: role in coronary occlusion complicating percutaneous transluminal coronary angioplasty. J Am Coll Cardiol. 1985 Feb;5(2 Pt 1):198-202.
3. Denardo SJ, Morris NB, Rocha-Singh KJ, Curtis GP, Rubenson DS, Teirstein PS.  Safety and efficacy of extended urokinase infusion plus stent deployment for treatment of obstructed, older saphenous vein grafts. Am J Cardiol. 1995 Oct 15;76(11):776-780.
4. Feldman RC. Transcatheter aspiration of a thrombus in an aortocoronary saphenous vein graft. Am J Cardiol. 1987 Aug 1;60(4):379-380.
5. Lablanche JM, Fourrier JL, Gommeaux A, Becquart J, Bertrand ME. Percutaneous aspiration of a coronary thrombus. Cathet Cardiovasc Diagn. 1989 Jun;17(2):97-98.
6. Brosh D, Bartorelli AL, Cribier A, et al; for the Acolysis Registry Study Group. Percutaneous transluminal therapeutic ultrasound for high-risk thrombus-containing lesions in native coronary arteries. Catheter Cardiovasc Interv. 2002 Jan;55(1):43-49.
7. Moscucci M, Punamiya K, Ricciardi MJ.  Guide catheter thrombectomy during percutaneous coronary interventions for acute coronary syndromes. Catheter Cardiovasc Interv. 2000 Feb;49(2):192-196.
8. Ben-Dor I, Pichard AD, Waksman R. Combined mechanical and pharmacological approach to a thrombus-containing lesion. Catheter Cardiovasc Interv. 2010 May 1;75(6):972-976.
9. Onoda S, Mutoh M, Ishikawa T, et al. Usefulness of a 6 fr right judkins catheter for mechanically extracting a massive intracoronary thrombus from an ectasic right coronary artery: a report on two different cases of thrombectomy. Jpn Heart J. 2004 Jul;45(4):673-678.

Editorial Comments: While aspiration thrombectomy is routinely used to remove thrombus burden in STEMI, sometimes it is unable to remove large thrombus load. Rheolytic thrombectomy of AngioJet is very effective in that setting but requires a device set up and console. The authors describe another unique technique of using a smaller guide catheter for suction using two guide wires in the vessel; one guide wire remaining in the artery for quick access. Clearly this established technique has the advantage of very strong suction, so caution should be exercised to avoid guide catheter dissection. Hence, it should be used as the last resort.

– Samin K. Sharma, MD

Mount Sinai Medical Center, New York, NY

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From the Department of Cardiology, GB Pant Hospital and Associated Maulana Azad Medical College, New Delhi, India.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted August 11, 2011 and accepted August 29, 2011.
Address for correspondence: Mohit D Gupta, MD, DM, Assistant Professor of Cardiology, Room 125, Academic Block, First Floor Dept of Cardiology, GB Pant Hospital, New Delhi-110002. Email: drmohitgupta@yahoo.com