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MINI-FOCUS ISSUE: COMPLICATIONS

CASE REPORT: TECHNICAL CORNER

A Mechanism for Stroke ComplicatingCoronary Thrombus Aspiration

Tanawan Riangwiwat, MD, Mark Schneider, DO, James C. Blankenship, MD, MHCM

ABSTRACT

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Coronary thrombus aspiration was developed to remove thrombus, prevent distal embolization, and prepare the vessel

for definitive intervention. However, its use is now limited by the risk of stroke. We describe a case where appropriate

aspiration technique likely prevented central embolization of a coronary thrombus. (Level of Difficulty: Beginner.)

(J Am Coll Cardiol Case Rep 2020;2:898–901) © 2020 The Authors. Published by Elsevier on behalf of the

American College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND license

(http://creativecommons.org/licenses/by-nc-nd/4.0/).

A spiration thrombectomy during ST-segmentelevation myocardial infarction (STEMI) hasbeen associated with excess risk of stroke

(1). We hypothesize that stroke may be caused byincomplete aspiration of embolus through an aspira-tion catheter, dislodgement as the aspiration cath-eter is withdrawn from the guide catheter, andsubsequent injection from the guide catheter intothe general circulation. We report a case where thefirst 2 steps of this 3-step sequence occurred, andthe final step, ejection of a thrombus through theguide catheter, was averted only by careful flushingof the guide and Tuohy connector. We propose stra-tegies to avoid stroke during coronary thrombusaspiration.

EARNING OBJECTIVES

To review the risk and benefit of thrombusaspiration in the setting of STEMI.To present appropriate thrombus aspirationtechnique in order to prevent thrombusembolization into the systemic circulation.

N 2666-0849

m the Department of Cardiology, Geisinger Medical Center, Danville, Pen

relationships relevant to the contents of this paper to disclose.

e authors attest they are in compliance with human studies committe

titutions and Food and Drug Administration guidelines, including patien

it the JACC: Case Reports author instructions page.

nuscript received March 5, 2020; revised manuscript received April 23, 2

HISTORY OF PRESENTATION

A 54-year-old woman presented with retrosternalchest pain and electrocardiogram showing inferiorSTEMI.

PAST MEDICAL HISTORY

The patient’s medical history included hypertension,diabetes mellitus type 2, and obstructive sleep apnea.

DIFFERENTIAL DIAGNOSIS

Thrombotic coronary occlusion, aortic dissection,pericarditis, and takotsubo cardiomyopathy.

INVESTIGATION

Electrocardiography showed ST-segment elevation inthe inferior leads. Initial troponin T was negativeat <0.01 ng/ml.

MANAGEMENT

The patient was treated with aspirin 324 mg, clopi-dogrel 600 mg, and heparin 100 U/kg. Supplemental

https://doi.org/10.1016/j.jaccas.2020.05.007

nsylvania. The authors have reported that they have

es and animal welfare regulations of the authors’

t consent where appropriate. For more information,

020, accepted May 5, 2020.

FIGURE 1 Initial Right Coronary Artery Angiogram Showing

Obstructive Thrombus Characterized by Lucency With

Contrast on 3 Sides

AB BR E V I A T I O N S

AND ACRONYM S

RCA = right coronary artery

STEMI = ST-segment elevation

myocardial infarction

TA = thrombus aspiration

J A C C : C A S E R E P O R T S , V O L . 2 , N O . 6 , 2 0 2 0 Riangwiwat et al.J U N E 2 0 2 0 : 8 9 8 – 9 0 1 Thrombus Aspiration and Stroke

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heparin was given to maintain the activated clottingtime between 250 and 300 s throughout theprocedure.

Coronary angiography 3 h after the onset ofsymptoms showed a dominant right coronary artery(RCA) with a 100% proximal stenosis (Figure 1).Passing a 0.014-inch wire produced distal flow and

FIGURE 2 Right Coronary Artery After Passing Wire and

Initial Aspiration With Aspiration Catheter

demonstrated extensive thrombus filling theentire RCA (Figure 2, Video 1). Passes with anExport XT catheter (Medtronic, Dublin,Ireland) yielded several large thrombi. On thethird pass of the catheter, blood returnthrough the catheter stopped prematurely,and the aspiration catheter was withdrawn

from the guide catheter with constant suction, takingcare that the guide catheter was deeply engaged inthe ostium of the RCA. A thrombus was visible pro-truding from the aspiration port of the guide catheter(Figure 3). Residual thrombus persisted in the prox-imal artery, and now the posterior descending branchwas noted to be occluded by thrombus (Figure 4,Video 2). Intravenous double bolus eptifibatide wasadministered. Additional passes of the aspirationcatheter were made including into the posteriordescending branch. On one of these passes, bloodreturn again stopped prematurely, and the catheterwas withdrawn. The aspiration catheter was removedfrom the Tuohy connector without visible thrombus,so the Tuohy connector was flushed as follows: weopened the bleedback control seal by pressing downthe cap until bleedback expelled any air and thenflushed backward through the bleedback control sealwith 10 ml of saline. This yielded a large linearthrombus (Figure 5) that adhered to the guidewire.The target lesion was stented with a 3.5- � 30-mmdrug-eluting stent. Final angiography showednormal distal flow and no residual thrombus(Figure 6, Video 3). Eptifibatide was continued for18 h. Electrocardiography immediately post-percutaneous coronary intervention procedureshowed resolution of ST-segment elevation. Peaktroponin T level was 8.47 ng/ml. The left ventricularfunction at discharge was grossly normal, but theinferior and posterior segments were inadequatelyvisualized to assess regional wall motionabnormality.

DISCUSSION

Three randomized trials have studied manual aspi-ration thrombectomy in STEMI patients (1–3). Severalmeta-analyses concluded that thrombus aspiration(TA) was not associated with reductions in mortalitybut was associated with statistically significant 50%excess in the incidence of stroke. Therefore, recentSTEMI guidelines downgraded routine TA in STEMIfrom a Class IIa recommendation to a Class IIIrecommendation, but retained a Class IIb recom-mendation for selective TA (4).

Among the randomized trials of TA, excess risk ofstroke was found only in the TOTAL (Trial of Routine

FIGURE 3 Thrombus Obstructed the Aspiration Port of the

Aspiration Catheter, With One-Half of the Thrombus

Still Protruding

FIGURE 4 Right Coronary Artery After Aspiration of the

Thrombus Depicted in Figure 3

Residual thrombus persists at the proximal lesion. The posterior

descending branch is occluded by thrombus.

FIGURE 5 Thrombus Being Flushed From the

Tuohy Connector

Riangwiwat et al. J A C C : C A S E R E P O R T S , V O L . 2 , N O . 6 , 2 0 2 0

Thrombus Aspiration and Stroke J U N E 2 0 2 0 : 8 9 8 – 9 0 1

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Aspiration Thrombectomy with PCI versus PCI Alonein Patients with ST elevation myocardial infarction)(1). It has been postulated that stroke associated withTA is technique-dependent, and that the more carefultechnique in earlier trials prevented an excess ofstroke. The proposed mechanism of TA-associatedstroke involves a thrombus that could not be fullyaspirated through the aspiration catheter dislodginginside the guide catheter, and subsequently beinginjected through the guide catheter into the systemiccirculation. In the case reported here, the second timethat the flow of aspirate ended prematurely, we couldnot find a protruding thrombus. Suspecting it haddislodged in the Tuohy, we flushed the Tuohy,extruding a huge linear thrombus from the back end.Had we injected through the guide without flushingthe Tuohy, this thrombus would likely have embol-ized either into the coronary artery or into the generalsystemic circulation.

FOLLOW-UP

At 1-month follow-up, the patient was asymptomatic.

CONCLUSIONS

When performing aspiration thrombectomy, it iscritical to monitor flow through the aspiration sy-ringe; reduced or absent flow may indicate

FIGURE 6 Final Angiography of the Right Coronary Artery

After Stenting

J A C C : C A S E R E P O R T S , V O L . 2 , N O . 6 , 2 0 2 0 Riangwiwat et al.J U N E 2 0 2 0 : 8 9 8 – 9 0 1 Thrombus Aspiration and Stroke

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thrombotic obstruction in the aspiration catheter.Special care should be taken to prevent embolization:1) insert the guide catheter deeply into the artery sothat if thrombus dislodges from the aspiration cath-eter as it is withdrawn, it will not enter the aorta; 2)provide continuous suction to the aspiration catheteras it is withdrawn; 3) aspirate blood from the guidecatheter after withdrawal of the aspiration catheter toremove any thrombus that is dislodged during cath-eter withdrawal; and 4) flush the Tuohy connectorbackward after aspiration catheter withdrawal.Future studies of TA should specify techniques to beused for the TA procedure.

ADDRESS FOR CORRESPONDENCE: Dr. James C.Blankenship, Department of Cardiology, 100 NorthAcademy Avenue, MC: 27-75, Geisinger Medical Center,Danville Pennsylvania 17822. E-mail: jblankenship@geisinger.edu. Twitter: @jblanke87916685,@Tanawan_Mai.

RE F E RENCE S

1. Jolly SS, Cairns JA, Yusuf S, et al. Outcomesafter thrombus aspiration for ST elevationmyocardial infarction: 1-year follow-up of theprospective randomised TOTAL trial. Lancet 2016;387:127–35.

2. Vlaar PJ, Svilaas T, van der Horst IC, et al.Cardiac death and reinfarction after 1 year in theThrombus Aspiration during Percutaneous coro-nary intervention in Acute myocardial infarctionStudy (TAPAS): a 1-year follow-up study. Lancet2008;371:1915–20.

3. Frobert O, Calais F, James SK, Lagerqvist B.ST-elevation myocardial infarction, thrombusaspiration, and different invasive strategies. ATASTE trial substudy. J Am Heart Assoc 2015;4:e001755.

4. Levine GN, Bates ER, Blankenship JC, et al.2015 ACC/AHA/SCAI focused update on primarypercutaneous coronary intervention for patientswith ST-elevation myocardial infarction: an updateof the 2011 ACCF/AHA/SCAI guideline for percu-taneous coronary intervention and the 2013

ACCF/AHA guideline for the management of ST-elevation myocardial infarction. J Am Coll Cardiol2016;67:1235–50.

KEY WORDS percutaneous coronaryintervention, stroke, thrombus

APPENDIX For supplemental videos,please see the online version of this paper.