Cath Lab Digest - April 2008 - (Page 29)

29 catheter is advanced — it is not uncommon for the guidewire to advance during this maneuver. 6. Advance the aspiration catheter through the entire length of occlusive disease. 7. Maintain aspiration for longer duration in the dense portion of the thrombus. 8. Maintain aspiration rate by maintaining negative pressure during advancement and withdrawal of the catheter. 9. Watch the guide catheter as aspiration catheter is withdrawn: a. Anecdotal reports of the guiding catheter getting sucked in. b. It may cause trauma to proximal vessel (e.g., left main). c. Consider releasing the negative pressure while withdrawing the catheter. 10. If no suction of blood despite appropriate preparation and lesion selection: a. The aspiration lumen may be plugged with thrombus. In this case, withdraw and flush the catheter, and repeat the procedure. 11. Additional passes may be needed for bulky thrombus. 12. If thrombus burden is unchanged after two passes with appropriate technique and the vessel anatomy is suitable, consider a switch to the AngioJet. Portions of this article were reprinted with permission from Mehta S. Chapter 8: Practical Guidelines for Performing STEMI Interventions. In: Mehta S, ed. Textbook of STEMI Interventions. Malvern, PA: HMP Communications, 2008:113-130. ■ Dr. Mehta can be contacted at mehtas@bellsouth.net References 1. Fischman DL, Savage MP, Leon MB, et al. Fate of lesion-related side branches after coronary artery stenting. J Am Coll Cardiol 1993; 22:1641–1646. 2. Aliabadi D, Tilli FV, Bowers TR, et al. Incidence and angiographic predictors of side branch occlusion following high-pressure intracoronary stenting. Am J Cardiol 1997; 80:994–997. 3. Poerner TC, Kralev S, Voelker W, et al. Natural history of small and medium-sized side branches after coronary stent implantation. Am Heart J 2002; 143:627–635. 4. Crossman AW, D'Agostino HJ, Geraci SA. Timing of coronary artery bypass graft surgery following acute myocardial infarction: a critical literature review. Clin Cardiol 2002; 25(9):406–410. 5. Palmerini T, Marzocchi A, Marrozzini C, et al. Comparison between coronary angioplasty and coronary artery bypass surgery for the treatment of unprotected left main coronary artery stenosis (the Bologna Registry). Am J Cardiol 2006. 98(1):54–59. 6. Henriques JPS, Zijistra F, Ottervanger JP, et al. Incidence and clinical significance of distal embolization during primary angioplasty for AMI. Eur Heart J 2002; 23:1112–1117. 7. Napodano M, Pasquetto G, Sacca S, et al. Intracoronary thrombectomy improves myocardial reperfusion in patients undergoing direct angioplasty for acute myocardial infarction. J Am Coll Cardiol 2003; 42:1395–1402. Antoniucci D, Valenti R, Migliorini A, et al. Comparison of rheolytic thrombectomy before direct infarct artery stenting versus direct stenting alone in patients undergoing percutaneous coronary intervention for acute myocardial infarction. Am J Cardiol 2004; 93:1033–1035. Lefevre T, Garcia E, Reimers B, et al. X AMINE ST Investigators. X-sizer for thrombectomy in acute myocardial infarction improves ST-segment resolution: results of the X-sizer in AMI for negligible embolization and optimal ST resolution (X AMINE ST) trial. J Am Coll Cardiol 2005; 46:246–252. Burzotta F, Trani C, Romagnoli E, et al. Manual thrombus-aspiration improves myocardial reperfusion: the randomized evaluation of the effect of mechanical reduction of distal embolization by thrombusaspiration in primary and rescue angioplasty (REMEDIA) trial. J Am Coll Cardiol 2005; 46:371–376. Dudek D, Mielecki W, Legutko J, et al. Percutaneous thrombectomy with the RESCUE system in acute myocardial infarction. Kardiol Pol 2004; 61:523–533. De Luca L, Sardella G, Davidson CJ, et al. Impact of intracoronary aspiration thrombectomy during primary angioplasty on left ventricular remodelling in patients with anterior ST-elevation myocardial infarction. Heart 2006; 92:951–957. Ali A, Cox D, Dib N, et al. Rheolytic thrombectomy with percutaneous coronary intervention for infarct size reduction in acute myocardial infarction: 30-day results from a multicenter randomized study. J Am Coll Cardiol 2006; 48:244–252. Antoniucci D, Valenti R, Migliorini A, et al. Comparison of rheolytic thrombectomy before direct infarct artery stenting versus direct stenting alone in patients undergoing percutaneous coronary intervention for acute myocardial infarction. Am J Cardiol 2004; 93:1033–1035. Table 2. TIMI Thrombus Grade 8. 0 1 No cineangiographic characteristics of thrombus present. Possible thrombus present. Angiography demonstrates characteristics such as reduced contrast density, haziness, irregular lesion contour or a smooth convex “meniscus” at the site of total occlusion suggestive but not diagnostic of thrombus. 9. 2 3 Thrombus present, small size: Definite thrombus with greatest dimensions less than or equal to 1/2 vessel diameter. Thrombus present, moderate size: Definite thrombus but with greatest linear dimension greater than 1/2 but less than 2 vessel diameters. Thrombus present, large size: As in Grade 3, but with the largest dimension greater than or equal to 2 vessel diameters. Total occlusion. 11. 10. 4 5 Sources: 1. The TIMI-IIIA Investigators. Early effects of tissue-type plasminogen activator added to conventional therapy on the culprit coronary lesion in patients presenting with ischemic cardiac pain at rest. Circulation 1993;87:38–52. 2. van’t Hof AW, Liem A, Suryapranata H, et al. Angiographic assessment of myocardial reperfusion in patients treated with primary angioplasty for acute myocardial infarction: myocardial blush grade. Zwolle Myocardial Infarction Study Group. Circulation 1998;97: 2302–2306. 12. 13. Table 3. Strategy for PCI and Aspiration/Atherectomy Based on Thrombus Grade Grade 0 - 1 Grade 2 - 3 Grade 4 - 5 Direct stenting, with or without predilatation Aspiration atherectomy followed by percutaneous coronary intervention. AngioJet atherectomy 14. http://www.modulardevices.com http://www.modulardevices.com

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Cath Lab Digest - April 2008 Kaiser San Rafael Medical Center Orbital Atherectomy: A New Treatment for Complex Peripheral Arterial Disease Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab Contents Clinical Editor’s Corner CEU Education Center The Missing Link in STEMI Interventions — Thrombus Aspiration during Primary Percutaneous Coronary Intervention Predicting Stent Thrombosis Using A Clinical Risk Score Use of a New Guidewire: The Tigerwire Should I Stay or Should I Go? Weighing Options for New Opportunities Navigating Tortuous Coronary Sinus Anatomy Using a Bipolar Lead The National Society of Radiology Practitioner Assistants (NSRPA) Holds 9th Annual Educational Conference For Medical Imaging Physician Extenders and Mid-Level Healthcare Providers Cath Lab & Beyond: A Meeting Update The Ten-Minute Interview with… Dale Hansen RT, CVT Sometimes, You Just Know Twin Circumflex Arteries: A Rare Coronary Artery Anomaly What Do You Think? Meetings Calendar News from the American College of Cardiology (ACC) Scientific Session and the Society of Cardiovascular Angiography & Interventions (SCAI) Annual Scientific Sessions in Partnership with the ACC i2 Summit Clinical & Industry News Cath Laughs Classifieds Advertisers Index

Cath Lab Digest - April 2008

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