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[ Scientific Activity - Actividad Científica ] [ Discussion Forum - Foro de Discusión ]

Interventional CV Rounds

Coordinator: Dr. Hugo Londero
Moderator: Dr. Raúl Bretal

Case number 3: Thrombus containing lesion in Unstable Angina
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Opinion of Dr. Ramón Quesada
Opinion of Dr. Jorge Belardi
Case Resolution

Opinion of Dr. Ramón Quesada
Medical Director, Interventional Cardiology
Miami Cardiovascular Institute

This is a very interesting case of a patient with acute ischaemic coronary syndrome unstable angina. A cardiac catheterization is showing a complex lesion in the circumflex coronary artery involving the bifurcation of the obtuse marginal with a thrombus- containing lesion. The right coronary artery is free of critical disease and LAD has some disease with normal left ventricular function.

We have learned from the era of plain balloon angioplasty that the most important predictor of acute closure during coronary intervention was the presence of thrombus. Data from Coly and looking at 1,857 patients, 14% of acute closure with the presence of thrombus were found and only 7% when thrombus was not present in-patients with ischaemic coronary syndrome. Ellis et al of 450 patients reproduced this data, 14% presented acute closures with thrombus versus 9% of patients who did not have thrombus containing lesions. From those early observations, we learned that if we could treat those patients with anticoagulants for several days before attempting intervention, we would reduce the incident of acute myocardial infarction, emergency coronary bypass surgery and mortality.

We also learned that the use of intracoronary thrombolytics in-patients with unstable angina and thrombus containing lesions were associated with higher complications rates. This was demonstrated in the TAUSA Trial.

In the area of coronary stenting, Carlos Macaya and his group have shown us that the use of stenting in thrombus containing lesions were not associated with increased morbidity, and became the standard of therapy, including in patients with acute myocardial infarctions.

I would say that the most important development in interventional cardiology in the early to mid 90’s was the introduction of the Iib/IIIa Receptor Antagonists in the Interventional arena. We learned from the earlier trials, using Abciximab: EPIC, EPILOG and CAPTURE Trial, that there was up to a 50% reduction of ischaemic events in those patients who had acute ischaemic coronary syndrome and unstable angina and received Abciximab as adjunctive therapy in complex coronary interventions. When we look at the subgroup analysis in those three trials, those who received Abciximab in addition to stenting were the ones who benefited the most with an additional 20% reduction in ischaemic complications.

Therefore, it’s clear that in the area of IIb/IIIa Inhibitors the management of thrombus containing lesions has changed dramatically. In this particular case, we will initiate this patient on a IIb/IIIa Inhibitor Bolus and infusion, primary stenting if possible and very likely Y-stenting.

I would like to also mention that there are other mechanical forms of treating thrombus - containing lesions. Such as the use of AngioJet and Acolysis, which we use primarily when there is a significant amount of thrombus burden, and the use of IIb/IIIa Inhibitors alone would not be sufficient to resolve the problem.

Also important is the introduction of distal protection devices to prevent embolization during coronary interventions i.e. lesions containing thrombus. There are three devices under investigation and hopefully will approved for clinical use.

In conclusion, in the practice of interventional cardiology today and the management of patients with acute ischaemic coronary syndrome and thrombus containing lesions the use of IIb/IIIa Inhibitors has been a major development and is the standard of therapy in the cath lab.

It has proven to reduce ischaemic complications and should be used as an adjunctive therapy to PTCA and stenting. The use of Thrombectomy devices in lesions with large "thrombus burden" and in the near future, the use of distal protection to prevent distal embolization during intervention.


Opinion of Dr. Jorge Belardi
Director, Division of Cardiology
Instituto Cardiovascular de Buenos Aires

Circumflex artery; this patient has a severe thrombotic lesion previous to a bifurcation between the post lateral and the post ventricular. The LAD has a significant lesion in the middle third although this one is a small vessel of non-optimal evolution and could be left for a second procedure after the acute problem is being solved.

The tactic I suggest to follow would be to administer anti IIb/IIIa, two intracoronary guides and dilatation with balloon of the most important branch, with probability of stent implantation, leaving the second branch for alternative balloon treatment and not for a kissing stent.


Case Resolution

We agree with the panelists, that in patients with unstable angina and thrombus containing lesions it is better to stabilize the patient prior to intervention. However, this patient continued with rest pain episodes despite of the medical therapy that includes intravenous Heparin. Thus the patient was considered refractory and the procedure was performed.

A bolus of abciximab was administered prior to the procedure and the infusion was continued during 12 hours.

The lesion was crossed with two wires, and successive predilatations were performed in both branches; then the wire in the secondary branch was removed and a MultiLink stent 3.0 mm by 23 mm in length was implanted in the main vessel. This caused a transient occlusion of the side branch.(Figure N 4 - A). The occluded vessel was crossed again with the wire and was treated with balloon angioplasty, (Figure N° 4- B) reperfusion was obtained with an acceptable angiographic result (Figure N°4 - C).

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The T stenting technique was not attempted because of the small diameter of the secondary vessel

The patient had a good outcome and was discharged 24 hours later.


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