«Catch me if you can» A s3cky thrombus problem. Dr F. De Vroey (JEUNE ) Grand Hôpital De Charleroi Belgique
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1 «Catch me if you can» A s3cky thrombus problem Dr F. De Vroey (JEUNE ) Grand Hôpital De Charleroi Belgique
2 Clinical case 39- y- old female, ac3ve smoker Presented with 48 hours of inconstant chest pain Unremarkable clinical examina3on ECG: slight ST- eleva3on in the anterior territory with biphasic T wave inversion Transthoracic echo (TTE): preserved leh ventricular ejec3on frac3on with no regional wall mo3on abnormality
3 Urgent coronary angiogram: radial approach Mid RCA occlusion (CTO)
4 Urgent coronary angiogram: radial approach Mid RCA occlusion (CTO) Large sub- occlusive thrombus in the mid- LAD
5 Primary PCI: part I Despite Pre- loading with 3cagrelor numerous runs of thrombectomy IV Abxicimab Recover (Hexacath, France) Persistence of a large thrombus burden with sluggish TIMI flow
6 Primary PCI: part I
7 Que ferait un «Sage»? Dr Tron 7
8 Comment ferait le vieux Christophe TRON CHU de Rouen
9 Volumineux thrombus IVA Risque majeur d embolisa3on distale et de no- reflow Traitement pharmacologique dans un 1 er temps : Aspirine, 3cagrelor ou prasugrel Enoxaparine 48 h An3 IIb/IIIa Contrôle à 48 h si absence de récidive douloureuse
10 Volumineux thrombus IVA Risque majeur d embolisa3on distale et de no- reflow Abciximab Héparine Aspira3on manuelle (7 F?) Suite de la procédure à adapter en fonction du résultat obtenu
11 Volumineux thrombus IVA Flux TIMI 3 Abtude MIMI Flux TIMI 2 Ballon sous- dimensionné Alteplase 15 mg IC bolus ± 35 mg Système de protec3on? Traitement du no- reflow (adénosine, verapamil, nitroprussiate)
12 Et maintenant, Comment a fait le jeune? 12
13 How to proceed from now? 1. Change thrombectomy catheter (bigger lumen) and try again 2. Halt the procedure now and retry aher 24 hours of GP IIbIIIa therapy 3. Proceed to IVUS to discriminate between parietal thrombus and spontaneous dissec3on 4. Place a filter wire and carry on with the PCI 5. Get on with it and s3ck a long stent Due to on- going chest pain, ahempt to displace the thrombus with gentle balloon inflakon
14 Primary PCI: part II 2,5 x 15 mm regular balloon, 10 atm 3,0 x 20 mm regular balloon, 8 atm Successful thrombectomy Export (Medtronic, USA)
15 Primary PCI: part II 2,5 x 15 mm regular balloon, 10 atm 3,0 x 20 mm regular balloon, 8 atm Distal emboliza3on Successful thrombectomy Export (Medtronic, USA)
16 Primary PCI: part III
17 Primary PCI: part III Decision to implant of a bio- absorbable stent Absorb (Abbom, USA) Proximal marker BVS Distal marker BVS
18 Primary PCI: part III Decision to implant of a bio- absorbable stent Absorb (Abbom, USA) Post- infla3on Proximal marker BVS Post- dilata3on Distal marker BVS NC 4,0 x 15 mm
19 Final angiographic result: Pa3ent discharged at day 2 with normal control TTE and very limited enzymes rise
20 Final angiographic result: TIMI flow III, resolu3on of chest pain and ECG changes Proximal marker BVS Distal marker BVS Pa3ent discharged at day 2 with normal control TTE and very limited enzymes rise
21 Discussion Large thrombus burden: «tricky to handle» Large parietal thrombus = limle effect of aspira3on KT Time delay «symptoms - PTCA»: reduced effect of an3thrombo3c therapy Posi3oning of the BVS: Be aware of the balloon markers and stent markers rela3onship
22 Relationship of Scaffold Markers to Delivery Catheter Markers Outer Edge of Scaffold Markers Scaffold Edges Data on file at Abbott Vascular
23 Relationship of Scaffold Markers to Delivery Catheter Markers Scaffold Leading Edge Balloon Marker Scaffold Markers Data on file at Abbott Vascular
24 Scaffold Marker Bead Posi3oning 3.5 mm Absorb Distal End Proximal End P D Stage Proximal End P! Distance from Outer Edge of Marker Beads to Edge of Proximal End Ring (mm) Stage Distal End D! Distance from Outer Edge of Marker Beads to Edge of Distal End Ring (mm) Crimp 1.4 Crimp 0.3 Expn Expn Expn Expn Data on file at Abbott Vascular
25 Scaffold Marker Bead Posi3oning 2.5/3.0 mm Absorb Distal End Proximal End D P Stage Proximal End P! Distance from Outer Edge of Marker Beads to Edge of Proximal End Ring (mm) Stage Distal End D! Distance from Outer Edge of Marker Beads to Edge of Distal End Ring (mm) Crimp 1.1 Crimp 0.3 Expn Expn Expn Expn Expn Expn Data on file at Abbott Vascular
26 Merci pour votre ahenkon Your comments are welcome! (des jeunes et des sages )
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