No-Stent Management of High Coronary Thrombus Burden in Young Patients with STEMI: A Four-Case Series

Atherosclerotic plaque rupture is the most common mechanism underlying ST-segment elevation myocardial infarction (STEMI); however, young patients (≤50 years old) may present with a massive coronary thrombus in the absence of clearly demonstrated flow-limiting severe atherosclerotic stenosis. Routine direct stent implantation in these highly thrombotic lesions may increase the risk of distal embolization, impaired coronary blood flow, and long-term stent thrombosis. This report describes the angiographic outcomes of a retrospective case series of four young male patients managed without permanent stent implantation using tirofiban-based antithrombotic therapy, with or without initial mechanical reperfusion, guided by clinical stabilization and Thrombolysis in Myocardial Infarction (TIMI) flow. Tirofiban-based antithrombotic therapy was followed by substantial thrombus regression, while mechanical reperfusion was used when necessary to restore epicardial flow. In carefully selected patients with preserved coronary flow, a high thrombus burden, and no clearly demonstrated flow-limiting fixed lesion, a no-stent management strategy, with or without initial mechanical reperfusion, may be considered following individualized assessment and close angiographic follow-up.