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Management of intracoronary thrombosis complicating percutaneous transluminal coronary angioplasty
D R Boston1, A Malouf, W H Barry
1Division of Cardiology, University of Utah Medical Center, Salt Lake City 84132, USA.
Insights
Percutaneous transluminal coronary angioplasty (PTCA) has high success rates, but acute occlusion from intracoronary thrombus remains a risk. Management involves antiplatelet therapy, anticoagulation, and specific interventions for thrombus.
Area of Science:
- Cardiology
- Interventional Cardiology
Background:
- Percutaneous transluminal coronary angioplasty (PTCA) success rates exceed 90% due to technological and operator advancements.
- Acute periprocedural occlusion complicates ~6% of PTCA procedures, often caused by intracoronary (IC) thrombus.
Observation:
- Patients at highest risk for PTCA complications include those with acute ischemic syndromes or angiographically apparent thrombus.
- Management strategies for high-risk patients may involve prolonged heparin infusions, intracoronary thrombolytic therapy, or platelet glycoprotein IIb/IIIa receptor antagonists.
- Standard PTCA care includes adequate antiplatelet therapy (aspirin) and heparin, with activated clotting times (ACT) monitoring.
Findings:
- For IC thrombus post-intervention, initial treatment includes intracoronary nitroglycerin, followed by redilatation and intracoronary urokinase infusion.
- Prolonged balloon inflations, potentially with autoperfusion catheters, can be beneficial.
- Platelet glycoprotein IIb/IIIa receptor antagonists show potential benefit in managing IC thrombus complications.
Implications:
- Prompt and appropriate management of intracoronary thrombus is crucial to minimize PTCA complications.
- A multi-modal approach combining antiplatelet and anticoagulant therapies, with interventional strategies, is key.
- Emergency coronary artery bypass graft surgery may be necessary for refractory cases, highlighting the importance of timely intervention.
Abstract:
With technological advances in equipment and increased experience of operators, the success rates of percutaneous transluminal coronary angioplasty (PTCA) now exceed 90%. However, acute periprocural occlusion continues to complicate approximately 6% of all procedures, and many of these occlusions are due to intracoronary (IC) thrombus. Patients at highest risk for this complication include those with acute ischemic syndromes or with angiographically apparent thrombus. These individuals may be candidates for the use of prolonged heparin infusions prior to dilatation, intracoronary thrombolytic therapy, or monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor. All patients undergoing PTCA should receive adequate antiplatelet therapy, including aspirin, and heparin with dosing monitored by activated clotting times (ACT). In addition, some recommend the use of ionic contrast material. When IC thrombus accumulates following intervention, initial therapy should include IC nitroglycerin followed by a combination of redilatation and IC urokinase infusion. Prolonged balloon inflations may be useful, particularly with the use of autoperfusion catheters. Platelet glycoprotein IIb/IIIa receptor antagonists may prove to be beneficial in this situation as well. If the patient's clinical status deteriorates in spite of these measures, emergency coronary artery bypass graft surgery may be required.