Thread by @DrJayMohan

1/ For the fellows and #ACCEarlyCareer!

It’s a coronary thrombus! When to consider thrombectomy? What do you do? Let’s walk through this…#Tweetorial

#Cardiotwitter #Cardiology #STEMI

2/ Middle age patient with hx of CAD and PCI to LAD presents with significant SOB and elevated Hs-Trop. No chest pain. No ECG changes. Echo with inferior hypokinesis.

Here’s the diagnostic with a JR4.

Notice the filling defect in the RCA. This is thrombus. How do we know?

3/ Keys of #thrombus on angiogram

🔑 contrast staining
🔑 Lack of calcium on non con image
🔑 ovoid filling defect (complete lumen)

#Cardiotwitter #STEMI #TIMI

4/ Other key questions when encountering thrombus

❓Patient presentation (ACS?)
❓Hemodynamics
❓Presence of collaterals
❓Location/size

#cardiotwitter #STEMI #fellow #cardiology

5/ Thrombus-containing lesions (TCLs) seems to be associated with an increased risk of distal embolization and no or poor distal flow and low myocardial blush grades after percutaneous coronary intervention.

ahajournals.org/doi/10.1161/CI…

6/ 1st step- wiring

I usually try a soft (atraumatic tip <1g) first

Gives you information on if it’s fresh (wire flies) or more chronic

Try to finesse wire through rather than knuckle

Here I used a Runthrough NS Izanai

Nice to see wire take side branches (luminal)

7/ Here looks like I’m in the PLV. Wire seems like taking side branches. Hard to confirm.

Best way to confirm?

IVUS!

Also you can take a small balloon and Dotter lesion to create channel to see flow. I try not to do any distal injections in case I’m subintimal

8/ Here #IVUS showed I am true lumen. I like to confirm with CHROMA Flow and while I’m there I usually just throw VH (virtual histology) on.

@BotPci @RadialFirstBot

9/ I really have appreciated the use of ChromaFlow from my peripheral experience (SFA star technique, pioneer, etc) as well as VH (though fallen out of favor).

Knowing when something is soft and highly soft lipid helps you avoid over dilation/no/slow reflow #PAD #CAD

10/ So #IVUS and angio confirmed thrombus for me so to further prepare the vessel I decided to perform aspiration thrombectomy.

We don’t have CatRx yet however I do like the export because I can administer IC no reflow meds after aspiration to distal vessel #Stemi #cardiology

11/ It’s funny doing coronary #thrombectomy these days since the fellows all expect clot pics that #PE/#DVT gives us 🤣

Also I often hear fellows say “thrombectomy in coronaries is a class 3 indication”

Remember ROUTINE thrombectomy is class 3. You make decisions case by case

12/ Other options for #thrombectomy

🌪Rheolytic (Angiojet)
✂️Mechanical (Export)
💨Aspiration (CatRx)
💘Other (Guideliner manual)

13/ Results of CHEETAH 🐆 have been promising. I don’t have much experience yet with @PenVascular CATRx but I’ve heard great things.

My hospital still doesn’t have CatRX. Operators out there using this I would love to hear your experience! @JayMathewsMD

#Thrombectomy

14/ I’d advice both pre and post IC treatment of distal bed. I tend to use IC adenosine/nipride

No Reflow
•IC verapamil- 100-200 mcg
•IC nicardipine 100mcg
•IC Adenosine 20-100 mcg
•IC Nitroprusside 10-50 mcg
•IC Epinephrine 100-400mcg
•IC Aggrastat 10mcg/kg/min no data

15/ Next “gentle” balloon inflation with small flow and we have flow!

Gentle balloon= 4 ATMs= 58 PSI. As Rob Safian would say- there is no such thing as a gentle balloon. i prefer the Timmis “kiss from grandma” @BeaumontIC @trivaxheartmd @LuaySayed @amrabbasmd @AkhilGulati

16/ Got a little over confident I thought I could get a 38mm stent to the lesion (I was using a SAL 0.75 guide). Didn’t force it. Went with 5.5F guideliner with a little BAT and balloon anchoring.

NEVER advance guide extension without balloon leading!

17/ Stent deployed!

Pull that guideliner back (especially if you’re damp on pressures).

Before pulling stent balloon out get the guideliner within your stent to help assist the NC delivery! #Guideextension #cardiotwitter @BotPci @RadialFirstBot #radialfirst #pci

18/ Post dilate based on #IVUS.

Don’t be over aggressive (I tend to go 0.25 less than EEM of reference if no positive remodeling). End with a little IC nitro and take your final shot!

⭐️ Always asses prox vessel after using guide extension and aggressive guide.

19/ I love interventional cardiology because of the strategy that’s unique to each case and the technical skills you develop as you practice. Take everything you learn from each of your attendings (young and old) and make it your own!

#InterventionalCardiology

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