Thrombolysis: A Useful Tool in the Primary PCI Cupboard

J INVASIVE CARDIOL 2017;29(8):E98.

Key words: STEMI, thrombolysis

A 44-year-old woman presented to the emergency department with central crushing chest pain and dynamic anterior ST elevation on a background of a known left bundle-branch block on her electrocardiogram.

Past medical history included insulin-dependent diabetes, asthma, fibromyalgia, and a gradually failing kidney transplant (estimated glomerular filtration rate [eGFR], 17 mL/min). She was a smoker and gave definite history of allergy to heparin after previous procedure.

The patient was brought to the catheterization suite and treated with aspirin, ticagrelor, and 2.5 mg intravenous fondaparinux. She underwent coronary angiography using little contrast (25 mL). This revealed mild atheroma in both coronary arteries and a large intraluminal thrombus in her mid-left anterior descending (LAD) coronary artery. To avoid further contrast load associated with angioplasty procedure in view of her failing kidney transplant, the decision was made to thrombolyze with 3000 U tenecteplase into her left coronary artery (one-third the intravenous systemic dose), 2.5 mg intravenous metoprolol, and hydration. While still in the catheterization lab, her pain settled. Repeat coronary angiography 4 days later showed complete resolution of her mid-LAD thrombus, with only a small non-obstructive atheroma. Renal function remained stable, echocardiography revealed only mild left ventricular impairment, and the patient was discharged on aspirin, ticagrelor, statin, and beta-blocker. 

This case was challenging due to failing kidney transplant, allergy to heparin, and contraindication to glycoprotein IIb/IIIa antagonists (eGFR <30 mL/min). Intracoronary thrombolysis proved very effective in the treatment of the thrombus due to a presumed ruptured plaque. A similar approach was previously shown to dissolve angiographic thrombus and improve the TIMI flow in patients who developed no-reflow, distal embolization, or visible intracoronary thrombus during percutaneous coronary intervention.¹ In a small registry study of 30 ST-elevation myocardial infarction (STEMI) patients with a large thrombus burden and failed manual aspiration, local fibrinolysis with one-third of the systemic dose (half received also glycoprotein IIb/IIIa antagonists) reduced the thrombus burden, and improved epicardial flow and myocardial reperfusion at no cost of major bleeds.²

Our case demonstrates the rarely utilized niche role for intracoronary thrombolysis in STEMI treatment in the modern angioplasty era.

References

1.    Kelly RV, Crouch E, Krumnacher H, Cohen MG, Stouffer GA. Safety of adjunctive intracoronary thrombolytic therapy during complex percutaneous coronary intervention: Initial experience with intracoronary tenecteplase. Catheter Cardiovasc Interv. 2005;66:327-332. 

2.    Boscarelli D, Vaquerizo B, Miranda-Guardiola F, et al. Intracoronary thrombolysis in patients with ST-segment elevation myocardial infarction presenting with massive intraluminal thrombus and failed aspiration. Eur Heart J Acute Cardiovasc Care. 2014;3:229-236.

From Worcestershire Royal Hospital, Cardiology Department, Interventional Fellow, Worcester, United Kingdom.

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 accepted January 11, 2017.

Address for correspondence: Konstantin Schwarz, MD, MRCP, PhD, Worcestershire Royal Hospital, Cardiology Department, Interventional Fellow, Worcester, WR05 1DD, United Kingdom. Email: konstantin.schwarz@gmx.net