Challenges in Primary PCI: How to Treat a Large Intracoronary Thrombus With TIMI 3 Flow?

Area of Science:

• Cardiology
• Interventional Cardiology
• Cardiovascular Medicine

Background:

• ST-segment elevation myocardial infarction (STEMI) often involves intracoronary thrombus.
• Management strategies for large thrombus with preserved flow (TIMI 3) require careful consideration.
• Stenting unobstructed arteries carries risks and benefits that need evaluation.

Purpose of the Study:

• To discuss the immediate management of large intracoronary thrombus in STEMI.
• To analyze the risks and benefits of stenting non-obstructive plaques.
• To explore optimal strategies for acute coronary syndromes with plaque erosion.

Main Methods:

• Case report highlighting clinical decision-making.
• Review of potent antithrombotic therapy protocols.
• Discussion of intracoronary imaging (e.g., optical coherence tomography) for plaque assessment.
• Consideration of deferred stenting versus immediate intervention.

Main Results:

• Potent antithrombotic therapy followed by imaging is a reasonable initial approach for large intracoronary thrombus in STEMI with TIMI 3 flow.
• Optical coherence tomography identified plaque erosion as the cause in a specific patient.
• Deferred stenting was a viable option for patients with plaque erosion and <70% residual diameter stenosis.

Conclusions:

• Initial management of large intracoronary thrombus in STEMI with TIMI 3 flow should prioritize potent antithrombotic therapy and subsequent imaging.
• Deferred stenting is a potential strategy for selected acute coronary syndrome patients with plaque erosion and minimal stenosis.
• Careful risk-benefit assessment is crucial when considering stenting in unobstructed arteries.