Thrombolysis-Guided Primary Percutaneous Coronary Intervention

J INVASIVE CARDIOL 2018;30(12):E154.

Key words: cardiac imaging, fibrinolysis, ST-segment elevation myocardial infarction, STEMI, thrombolysis

A 77-year-old woman presented with inferolateral ST-segment elevation myocardial infarction (STEMI). After administration of 250 mg acetylsalicylic acid and 180 mg ticagrelor, the patient was transferred to the catheterization laboratory. 

Left coronary angiogram revealed intermediate stenosis at the proximal left anterior descending coronary artery and significant ostial stenosis of the obtuse marginal (Figure 1A). Catheterization of the right coronary artery (RCA) ostium was not possible with the usage of multiple catheters (Judkins right-JR, Amplatz right-left, and multipurpose), not even by aortography or after selected aortography with the pigtail catheter positioned in the right sinus (Figure 1B; Video 1), left sinus, and non-coronary sinus (Figure 1C). As the patient became hemodynamically unstable, inotropes were administered, intra-aortic balloon pump was placed, and she was intubated. 

Due to the inability to visualize the RCA ostium and the hemodynamic instability, we decided to proceed with systemic thrombolysis with alteplase 70 mg in the catheterization laboratory. A few minutes after thrombolysis, we performed another aortography, at which point the RCA ostium was identified (Figures 1D and 1E; Video 2). The ostium was engaged with Universal and Fielder FC guidewires, followed by subsequent advancement of the JR catheter. We then performed percutaneous coronary intervention (PCI) with two drug-eluting stents (3.5 x 38 mm mid-distal and 3.5 x 24 mm proximal) and a final TIMI 3 flow (Figure 1F; Video 3). 

Thrombolysis in the cath lab has been tested in scenarios of acute pulmonary embolism, STEMI with massive intraluminal thrombus, and facilitated PCI with low-dose thrombolytic therapy. Our case highlights that fibrinolysis might still find new indications in the cath lab and play a key role for some challenging cases in the era of modern PCI.

Watch the accompanying video here.

From the ¹Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy; and ²Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Tzanis reports funding received from the European Society of Cardiology in the form of an ESC Training Grant. The remaining authors report no conflicts of interest regarding the content herein.

Manuscript accepted July 3, 2018. 

Address for correspondence: Dr. Francesco Giannini, Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Via Madonna di Genova, 1, 48033 Cotignola RA, Italy. Email: giannini_fra@yahoo.it