Preliminary experiences using X-sizer catheter for mechanical thrombectomy of thrombus-containing lesions during acute coronary syndromes

Acute Limb Ischemia

Acute limb ischemia is a vascular event presenting with sudden decrease in limb perfusion (of <14 days' duration) that threatens limb viability. Acute thrombosis of the native artery or graft makes up the bulk of etiopathogenesis. Prompt revascularization is the cornerstone of management of acute limb ischemia in limbs that have not undergone irreversible tissue and nerve damage. Amputation is performed in patients with irreversible tissue and nerve damage.

Ephedrine-induced acute myocardial infarction in a young athlete: a case of thrombus management

A case of acute myocardial infarction in a young athlete provoked by ephedrine abuse has been described in this study. An intracoronary thrombus found in the left anterior descending coronary artery at urgent angiography was successfully removed using the Pronto (Vascular Solutions, Minneapolis, Minnesota) aspiration catheter. The intravascular ultrasound examination performed thereafter showed a nonobstructive atherosclerotic plaque in the culprit artery; there was no evidence whatsoever of possible plaque disruption. The result of percutaneous coronary intervention was satisfactory, and no stent implantation was needed. The patient experienced no adverse events until his outpatient visit 3 months later.

Incidence, predictors, and outcomes of device failure of X-sizer thrombectomy: real-world experience of 200 cases in 5 years

BACKGROUND

Clinical studies have evaluated the safety and efficacy of adjunctive X-sizer (EndiCOR Inc, San Clemente, CA) in percutaneous coronary intervention (PCI). However, patient and lesion subsets were highly selected, and extrapolation of the results to daily practice is problematic.

METHODS

X-sizer thrombectomy was performed in 200 procedures from August 2000 to July 2005. The indications for the procedures were primary PCI in 71%. Device failure was defined as the occurrence of 1 or more of the following conditions: (a) failure of the X-sizer to reach the target segment, (b) failure to achieve final thrombolysis in myocardial infarction 3 flow, (c) slow flow or no-reflow, (d) distal embolization, and (e) coronary perforation.

RESULTS

Device failure occurred in 48 procedures, giving a device failure rate of 24%. Logistic regression analysis showed that ostial lesion was the only independent predictor of device failure (OR 4.89, 95% CI 1.23-19.51, P = .024). A total of 19 patients had developed 22 adverse events, giving a 30-day adverse event rate of 9.5%. Among these, there were 13 deaths, 4 strokes, 2 reinfarctions, 2 repeat PCIs, and 1 coronary artery bypass grafting. Logistic regression analysis showed that X-sizer device failure was independently associated with 30-day adverse events (OR 3.42, 95% CI 1.04-11.25, P = .043).

CONCLUSIONS

The incidence of device failure of X-sizer thrombectomy was 24%. Ostial lesion was an independent predictor of device failure. Notably, X-sizer device failure was independently associated with 30-day adverse event. These highlight the importance of case selection and the problem with its use in ostial lesions.

A pilot study with a new, rapid-exchange, thrombus-aspirating device in patients with thrombus-containing lesions: the Diver C.E. study

BACKGROUND

In patients with acute coronary syndromes (ACS), distal embolization of thrombotic material is more likely to play a key role in the pathogenesis of myocardial no-reflow during percutaneous coronary intervention (PCI). Thus, interventional techniques able to reduce thrombus burden at the culprit vessel might improve final myocardial reperfusion.

OBJECTIVE

To evaluate a new rapid-exchange thrombus-aspirating catheter, the Diver C.E., in patients with thrombotic coronary lesions undergoing PCI.

METHODS

Fifty patients with acute myocardial infarction (n = 44) or with non-ST-elevation ACS and angiographic evidence of coronary thrombus (n = 6) undergoing urgent PCI were prospectively enrolled. The Diver C.E. was used to aspirate coronary thrombus from the culprit lesion after placement of the guidewire. Adjunctive balloon inflations and stent implantation were used to achieve good angiographic result. Angiographic coronary flow (by means of TIMI score and corrected TIMI frame count, cTFC), thrombus score (TS), and myocardial perfusion (by means of postintervention myocardial blush grade, MBG) were assessed in all patients.

RESULTS

The device could be successfully employed in 96% of the cases (48/50) and yielded significant (P < 0.0001) acute reduction in thrombus burden (TS: predevice 3.5 +/- 0.8, postdevice 2.5 +/- 0.9) and improvement in coronary flow (TIMI grade: predevice 1.0 +/- 0.9, postdevice 2.0 +/- 0.9; CTFC predevice 71 +/- 31, postdevice 39 +/- 26). Final TIMI grade 0-1 was observed in one patient only (2%). A significant (P = 0.02) correlation was found between preintervention TS and efficacy of thrombus aspiration. A more pronounced acute reduction of thrombus burden after thrombus aspiration (TS reduction > or = 2) was associated with a better postintervention angiographic myocardial perfusion (MBG 2.3 +/- 0.9 vs 1.7 +/- 0.8; P = 0.05).

CONCLUSIONS

This new, easy-to-use, device is able to reduce thrombus burden and to improve coronary flow in patients with thrombus-containing lesions. The improvement in myocardial perfusion associated to greater thrombus removal highlights the importance of thrombus aspiration in the management of thrombus-burdened coronary lesions.

Instant dissolution of intracoronary thrombus by abciximab

Formation of intracoronary thrombus during percutaneous coronary intervention can lead to acute vessel closure and myocardial infarction if prompt action is not taken. Thrombus removal using mechanical thrombectomy is the common treatment approach. We report a rare case of thrombus formation immediately after guidewire advancement, causing acute myocardial ischemia. Intracoronary bolus of abciximab was given and this resulted in prompt dissolution of the thrombus. The procedure proceeded uneventfully and there was no myocardial damage. This is consistent with a recent report suggesting that intracoronary abciximab may be more beneficial than standard intravenous administration for patients undergoing emergency coronary intervention for acute coronary syndrome.

Persistent and proximal migration of a large coronary thrombus during percutaneous coronary intervention in the setting of acute Q-wave myocardial infarction

We describe a patient with an acute inferior myocardial infarction. Patient was taken to the cardiac catheterization laboratory for primary angioplasty. Angiography revealed 100% occluded proximal right coronary artery (RCA). After initial balloon angioplasty of the occluded RCA, a very large mobile thrombus was seen in the proximal RCA. Despite multiple stenting, suctioning through the guide catheter lumen, and intracoronary thrombolytic therapy, the thrombus persisted and migrated proximally after each stenting. However, patient did well despite of persistent large thrombus burden in the proximal RCA on aggressive antithrombotic treatment.

Left main coronary artery 'embolectomy' using a novel, straightforward technique

A 60-year-old man experienced catastrophic haemodynamic decompensation 3 days following coronary artery bypass grafting (CABG). Aspiration thrombectomy to remove a left main coronary artery saddle embolus resulted in immediate haemodynamic improvement with no requirement for angioplasty or repeat bypass grafting. Coronary thromboembolism should be considered in the differential diagnosis of haemodynamic collapse post CABG. Urgent coronary angiography and aspiration thrombectomy may result in significant improvement for this condition.

Effects of Percutaneous Coronary Thrombectomywith the X-Sizer Catheter on Epicardial Flow and Microvascular Function in Acute Coronary Syndromes

During percutaneous coronary intervention, slow coronary flow and distal embolization are still important problems, especially in cases with intracoronary thrombus. The aim of this study was to learn the effectiveness and early term results of thrombectomy with the X-SIZER catheter system in acute coronary syndrome. Twenty-nine patients (22 [76%] men; 55.9 ± 11.1 years) with acute coronary syndrome and intracoronary thrombus detected in coronary angiography were included into the study. X-sizer thrombectomy was applied to 14 of the patients, and conventional percutaneous transluminal coronary angioplasty (PTCA) was applied to the others. Baseline characteristics were similar in both groups. Mean thrombolysis in myocardial infarction (TIMI) flow increased from 0.8 ± 0.9 to 2.4 ± 0.6 in X-sizer-treated patients (p<0.001) and TIMI 3 flow was maintained in 71.4% of the patients. Similary, mean TIMI flow increased from 0.36 ± 0.81 to 2.73 ± 0.47 in conventional PTCA-treated patients (p<0.001) and TIMI 3 flow was maintained in 73% of the patients (NS). Mean myocardial blush grade (MBG) increased from 0.7 ± 0.7 to 2.6 ± 0.6 in X-sizer-treated patients (p<0.001) and from 0.27 ± 0.65 to 2.36 ± 0.67 in the conventional PTCA-treated patients (p<0.001). Postprocedural MBG 3 was obtained in 64.3% of X-Sizer-treated patients and in 45% of controls. Although microvascular function in the thrombectomy-applied patients was found better, there was no significant difference between the two groups. Furthermore it was detected that the use of tirofiban yielded no additional improvement in epicardial and microvascular flow. In acute coronary syndromes, use of X-sizer in addition to primary percutaneous coronary interventions is a safe and relatively effective method in the prevention of distal embolization.

Initial thrombosuction with subsequent angioplasty in primary coronary intervention—comparison with conventional strategy

BACKGROUND

Large thrombus burden remains challenging in the setting of acute myocardial infarct. Initial thrombosuction (IT) followed by actual angioplasty may be advantageous over conventional strategy in primary percutaneous coronary intervention (PCI).

METHODS

With a case-control design, 22 consecutive patients receiving primary PCI with IT were designated as group 1. Another 22 well-matched patients undergoing primary PCI with conventional strategy in the same period were enrolled as group 2. Clinical and angiographic outcomes, procedural parameters and resource usage were compared.

RESULTS

Baseline characteristics were comparable, including the symptom onset-to-needle time (250+/-101 vs. 261+/-149 min, p = NS). Total procedure time (33+/-14 vs. 47+/-20 min, p = 0.011), fluoroscopy time (10+/-6 vs. 16+/-10 min, p = 0.014) and contrast medium consumption (140+/-40 vs. 170+/-50 ml, p = 0.024) were all significantly reduced with group 1. No-reflow occurred less frequently with group 1 (5% vs. 32%, p = 0.046) during intervention, and TIMI 3 flow was established more quickly (19+/-10 vs. 30+/-20 min, p = 0.024). Final TIMI 3 flow rates and stent rates were similar. The time to myocardial enzyme peak was shorter with group 1 (9.7+/-3.1 vs. 12.8+/-6.3 h, p = 0.048), but no difference was found in 3 months cumulative major cardiac adverse event rates.

CONCLUSIONS

Primary PCI with IT achieves earlier reperfusion and is more efficient in terms of time and resource, comparing to conventional strategy.

Use of a New Thrombus Extraction Catheter (The ProntoR) in the Treatment of Acute Myocardial Infarction

The finding of an intracoronary thrombus at the time of coronary angiography is common in patients presenting with an acute coronary syndrome. Pharmacologic and mechanical treatment strategies have been developed and reported to facilitate the treatment of the thrombus along with a percutaneous coronary intervention. We report a case in which a Pronto thrombectomy catheter was utilized to facilitate thrombus removal prior to the placement of a coronary stent in a patient who developed postinfarct angina and pulmonary edema after successful thrombolytic therapy for a acute ST segment elevation myocardial infarction.

Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology

In patients with stable CAD, PCI can be considered a valuable initial mode of revascularization in all patients with objective large ischaemia in the presence of almost every lesion subset, with only one exception: chronic total occlusions that cannot be crossed. In early studies, there was a small survival advantage with CABG surgery compared with PCI without stenting. The addition of stents and newer adjunctive medications improved the outcome for PCI. The decision to recommend PCI or CABG surgery will be guided by technical improvements in cardiology or surgery, local expertise, and patients' preference. However, until proved otherwise, PCI should be used only with reservation in diabetics with multi-vessel disease and in patients with unprotected left main stenosis. The use of drug-eluting stents might change this situation. Patients presenting with NSTE-ACS (UA or NSTEMI) have to be stratified first for their risk of acute thrombotic complications. A clear benefit from early angiography (<48 h) and, when needed, PCI or CABG surgery has been reported only in the high-risk groups. Deferral of intervention does not improve outcome. Routine stenting is recommended on the basis of the predictability of the result and its immediate safety. In patients with STEMI, primary PCI should be the treatment of choice in patients presenting in a hospital with PCI facility and an experienced team. Patients with contra-indications to thrombolysis should be immediately transferred for primary PCI, because this might be their only chance for quickly opening the coronary artery. In cardiogenic shock, emergency PCI for complete revascularization may be life-saving and should be considered at an early stage. Compared with thrombolysis, randomized trials that transferred the patients for primary PCI to a 'heart attack centre' observed a better clinical outcome, despite transport times leading to a significantly longer delay between randomization and start of the treatment. The superiority of primary PCI over thrombolysis seems to be especially clinically relevant for the time interval between 3 and 12 h after onset of chest pain or other symptoms on the basis of its superior preservation of myocardium. Furthermore, with increasing time to presentation, major-adverse-cardiac-event rates increase after thrombolysis, but appear to remain relatively stable after primary PCI. Within the first 3 h after onset of chest pain or other symptoms, both reperfusion strategies seem equally effective in reducing infarct size and mortality. Therefore, thrombolysis is still a viable alternative to primary PCI, if it can be delivered within 3 h after onset of chest pain or other symptoms. Primary PCI compared with thrombolysis significantly reduced stroke. Overall, we prefer primary PCI over thrombolysis in the first 3 h of chest pain to prevent stroke, and in patients presenting 3-12 h after the onset of chest pain, to salvage myocardium and also to prevent stroke. At the moment, there is no evidence to recommend facilitated PCI. Rescue PCI is recommended, if thrombolysis failed within 45-60 min after starting the administration. After successful thrombolysis, the use of routine coronary angiography within 24 h and PCI, if applicable, is recommended even in asymptomatic patients without demonstrable ischaemia to improve patients' outcome. If a PCI centre is not available within 24 h, patients who have received successful thrombolysis with evidence of spontaneous or inducible ischaemia before discharge should be referred to coronary angiography and revascularized accordingly--independent of 'maximal' medical therapy.

Procedural efficacy and complications of X-Sizer thrombectomy in de novo and stented lesions

Angiographic thrombus is associated with poorer procedural and clinical outcomes. We report our experience with the X-Sizer thrombectomy device (EndiCOR Medical) from March 2001 to December 2002. Indications for use in 44 patients (33 male; mean age, 60) included myocardial infarction (27), unstable angina (6), periprocedural thrombosis (2), acute (< 24 hr) stent thrombosis (1), and subacute (> 24 hr) stent thrombosis (8). Three cases involved vein grafts. Deployment was successful in 42/44. Difficulty traversing the stent occurred in 5/9 cases of in-stent thrombosis. Median TIMI flow increased from 1 to 2 (P = 0.01) postthrombectomy. Median final TIMI flow was 3. Complications included dissection (1), perforation, device jam on stent (1), disruption of a covered stent (1), distal macro-embolization (4), and transient no-reflow (5). The X-Sizer thrombectomy device improves TIMI flow but does not always prevent distal embolization. Care is needed when treating in-stent thrombosis.