Case 217: Manual of CTO PCI - Thrombus Rx marathon

A patient was referred for PCI of a RCA in-stent CTO. Crossing was successful with a CrossBoss catheter, but the artery had a large thrombus burden. Despite multiple balloon dilations, aspiration with Penumbra and an Export catheter and administration of eptifibatide and vasodilator significant amount of thrombus remained as confirmed by OCT. The patient was admitted and received 48 hours of heparin and eptifibatide, but unfortunately he continued to have large thrombus burden on repeat angiography. After using a Filterwire, several rounds of aspiration with a Penumbra and through a guide extension, laser, multiple balloon dilations, use of the Solitaire X thrombus retriever (indicated for stroke interventions) and stenting the thrombus burden decreased and antegrade flow was restored. The patient had an uneventful recovery.

[@AhmedElborae]

Great and illustrative as usual! There are some reports also about off-label use of shock wave lithotripsy for thrombus fragmentation in such scenario. We have already evidence that Ultrasound +small dose lytic therapy showed a great results in the pulmonary tree (Ultima trial on EKOS), so i think this might be one of the future options for management of heavy thrombus burden. Thanks again for sharing , i have learnt alot from your book and video since the beginning of your great channel .

[@manosbrilakis]

Great point thank you!

[@shangz0216]

Thanks for the excellent case sharing.

[@Stentordoc]

As much as you were probably trying to avoid inserting more metal, I would have been tempted to just re-stent the mid to distal RCA to crush/trap that thrombus. Alas, no matter what is done, after all the PCI’s that the RCA has gone through, it’s not destined for long term patency anyway 😢

[@manosbrilakis]

Thank you / a concern for stenting after no reflow is that it may worsen the no reflow. Perhaps placing a filter could help if restenting is performed.

[@gthotakura]

Did you laser on contrast or saline?

[@karthikeyanselvaraj1801]

Sir ..how about a a distally inflated ballon..foll. by marination with IC lytics and suction..Ur personal xperience with marination especially in primary pci sir?

[@manosbrilakis]

This technique can be useful but I have not personally used it - one concern is that even with the balloon up there will be flow in side branches hence the lytic will wash away (except in SVGs that do not have side branches).

[@drmz2007]

What will be the antiplatelet strategy? Can we use oral anticoagulation with dual antiplatelet for few months and then re check Cag?

[@manosbrilakis]

I think that the risk of recurrent symptoms would be quite high - would want definitive treatment before discharging patient. Thank you!

[@drmz2007]

One more question sir Is there any role of low dose intracoronary thrombolytic agents in such a late presentation?

[@manosbrilakis]

This can be used - the concern is for increased risk of bleeding.