Use of PercuSurge GuardWire in Native Coronary Arteries During Acute Myocardial Infarction

One of the most challenging scenarios encountered during the percutaneous treatment of acute coronary syndromes (ACS) is the presence of thrombus, and the subsequent distal embolization due to mechanical disruption of the culprit lesion.¹ Resultant epicardial vessel and microvascular impedance to flow contributes to long-term left ventricular dysfunction, congestive heart failure and death.^2–5 Preventing distal embolization during percutaneous coronary intervention (PCI) in ACS is therefore of the utmost importance. The PercuSurge GuardWire (Medtronic, Minneapolis, Minnesota) is a device designed for transient balloon occlusion of the distal vessel during angioplasty or stent placement, allowing recovery of liberated plaque or thrombus by aspiration before restoration of antegrade flow. This device has been shown to be efficacious in saphenous vein graft (SVG) interventions.⁶ Studies are currently ongoing for use in native coronary arteries. We present 4 cases where the PercuSurge GuardWire was used in native coronary arteries during ACS. Case Report. Patient #1. A 72-year-old, female former smoker presented with an anterior ST-segment elevation myocardial infarction (STEMI). Angiography revealed a 100% mid-left anterior descending (LAD) artery occlusion, with angiographically visible thrombus extending to the distal LAD. The occlusion origin was immediately distal to the medium-sized first septal perforator and large-caliber first diagonal vessels, with thrombus extending beyond the second diagonal branch. Abciximab was used adjunctively, and heparin was administered to achieve a goal activated clotting time (ACT) of > 250 seconds. A short PercuSurge GuardWire was used to cross the lesion, and the occlusion balloon was inflated in the distal LAD, beyond the second diagonal artery. A 3.5 x 13 mm Bx Velocity stent (Cordis Corporation, Miami, Florida) was deployed in the proximal LAD and a 3.0 x 13 mm Bx Velocity stent was deployed in the mid-LAD. After aspiration using the PercuSurge Export catheter, TIMI 2 flow was established. Patient #2. A 56-year-old male with type 2 diabetes, hypertension and dyslipidemia presented with an inferolateral STEMI. Angiography revealed a 90% proximal circumflex thrombotic lesion with TIMI 2 distal flow. Abciximab was administered adjunctively, and heparin was administered to achieve a goal ACT > 250 seconds. A short PercuSurge GuardWire was used to cross the lesion, and the occlusion balloon was inflated in the large first obtuse marginal branch, distal to the smaller caliber atrioventricular circumflex branch bifurcation. Pre-dilation percutaneous transluminal coronary angioplasty (PTCA) was performed with a 3.0 x 20 mm Maverick balloon (Boston Scientific/Scimed, Inc., Maple Grove, Minneosta). Two stents were deployed, a 3.0 x 8 mm Penta stent (Guidant, Inc. Santa Clara, California) in the first marginal and a 3.0 x 13 mm Penta stent in the proximal circumflex. TIMI 3 distal flow was achieved. Patient #3. An 81-year-old male with diabetes and hypertension presented with a non-ST segment elevation myocardial infarction (NSTEMI) and persistent chest pain despite medical antianginal therapy. Angiography revealed a 99% proximal LAD occlusion with hazy appearance suggestive of thrombus, and distal TIMI 0 flow. Eptifibatide was initiated prior to the procedure, and heparin was administered for a goal ACT of > 250 seconds. A short PercuSurge GuardWire was used to cross the lesion, and the occlusion balloon was inflated in the mid LAD, distal to the first septal perforator and a medium-size first diagonal branch. Pre-dilation PTCA with a 3.0 x 15 mm Raptorail was performed and a 3.5 x 18 mm Bx Velocity stent was deployed. Final angiography revealed patent epicardial vessels and TIMI 2 flow without angiographically evident distal thrombus. Patient #4 (Figure 1). A 75-year-old female active smoker with diabetes, hypertension and dyslipidemia presented with an inferior STEMI. Angiography revealed a 90% mid circumflex lesion with large thrombus and TIMI 2 distal flow. Abciximab was administered adjunctively, and heparin was administered to achieve a goal ACT of > 250 seconds. A short PercuSurge GuardWire was used to cross the lesion. A 3.0 x 18 mm Hepacoat stent (Cordis) was deployed. TIMI 3 flow was restored, without evidence of distal embolization. Discussion. Despite remarkable advances in pharmacologic and percutaneous interventional modalities to treat acute coronary syndromes, distal embolization of thrombus and inadequate restoration of myocardial perfusion after PCI continues to be a major obstacle to optimal treatment of myocardial infarction. The PercuSurge GuardWire has been shown to improve outcomes in the setting of elective saphenous vein graft interventions by limiting distal embolization of friable debris from the culprit lesion to the distal circulation.⁶ Its potential role for use in the native coronary vessels during acute myocardial infarction (AMI) has yet to be defined. In this series, we present 4 cases of AMI where the culprit lesion demonstrated angiographically visible thrombus, and the PercuSurge GuardWire was used during PCI. No technical complications related to the device were encountered. There were no significant delays in treatment related to the device. All 4 patients received antithrombotic and antiplatelet therapy, and 3 of 4 received intracoronary vasodilators during PCI (Table 1). All patients had improvement in TIMI grade flow after PCI. Moreover, there were no further post-procedural elevations in CPK, and left ventricular function improved in all 4 cases (Table 2). Although there were no technical difficulties in this series, the PercuSurge GuardWire has been criticized for its relatively cumbersome set-up and the steerability of the wire itself, making it difficult or impossible to use in certain circumstances.⁷ The other major obstacle encountered with the use of the Percusurge GuardWire in the setting of native coronary occlusion is proper positioning of the occlusion balloon, so as to protect significant branches in close proximity to the culprit lesion from liberated debris, while allowing sufficient distal positioning of the balloon, to optimize entrapment of thromboemboli for subsequent aspiration. Finally, it is known that the phenomenon of slow-flow in the setting of primary PCI is not entirely due to embolization of thrombus from the epicardial vessels. Microvascular endothelial dysfunction, myocyte edema and local inflammatory mediators may all play a role in no-reflow that is unlikely to be totally prevented by the use of emboli protection devices. Pharmacologic agents aimed at improving myocardial reperfusion in this setting include adenosine, nitroprusside and calcium channel antagonists.^8,9 Whether such agents exert definitive independent benefit on clinical outcomes by reducing no-reflow is yet to be demonstrated. Despite these limitations, when combined with pharmacologic measures directed toward inhibition of thrombosis and platelet aggregation, and treatments promoting microvascular perfusion, the PercuSurge GuardWire can be utilized safely and effectively in the setting of ACS. The Enhanced Myocardial Efficacy and Recovery by Aspiration of Liberated Debris (EMERALD) Trial is a large-scale study with the aim of demonstrating an improvement in ST-segment resolution as well as reduction in infarct size after use of the PercuSurge GuardWire during AMI, versus PTCA/stenting without distal protection. Enrollment is currently ongoing and the results will likely contribute to our understanding of whether use of distal protection devices in this setting will improve myocardial function and ultimately improve clinical outcomes. In addition to distal occlusion devices, filter devices mounted on 0.014 mm guidewires have been successfully employed in peripheral vascular as well as saphenous vein graft interventions. Testing of these devices in the native coronary circulation will begin soon. In the future, such devices, in conjunction with second-generation occlusion/aspiration systems, will likely be easier to use, be capable of retrieving more debris, and hopefully further diminish the risk of distal embolization. As our understanding of the cellular and molecular mechanisms of myocardial injury during ACS continues to evolve, the sentinel concept developed almost 100 years ago by Dr. James B. Herrick that myocardial infarction is caused by sudden thrombotic coronary occlusion10 continues to be the primary target of interventional therapy today.