Okay, so this is a case of a large thrombus burden in STEMI. I will start at the beginning of the story, which was pre-STEMI. It's a 59-year-old man who was otherwise healthy who had presented with two months of chest pressure. He had a high-sensitive trope of 1,500 and the CKG on the right side with some T-wave inversions inferiorly, some peak Ts, and he was referred for cath. His EF was low normal with some basal inferior wall hypokinesis. Here is the first shot of the right coronary, which only fills partway there. And here is the left side, and you can see some robust collaterals from the left to the right, distal right. So wires put down and, you know, a little bit more flow, but you can see a lot of thrombus in there. We'll pause for a question. Just to jump in because I think it's an interesting coincidence. We just talked about this issue about guide selection, and I see you had a diagnostic there up front, and then it seems like you had an AL1 immediately afterwards. Were there any particular features here that you saw, I need more support? Yes. Well, so in this case, the patient presented with an NSTEMI, so it's more traditional that we would go with a diagnostic rather than the guide, and it did look up front that it was going to be a challenge, so having more support and having sort of the wisdom of seeing the diagnostic and then pulling a guide that had more support, I think, was helpful in this case. Dr. Abbott, any thoughts on how you would tackle this case here? You're on mute. Yeah, I mean, it'd be interesting to see how Dr. Young's team managed it because obviously it looks challenging for the N2 setup. I think the key is setting yourself up for success. I think when you see a difficult road ahead of you, you don't want to be escalating and escalating and escalating, so generally, I tend to have a strategy where I am up front, better guide support up front, using guideliners or microcatheters or equipment that can be escalated quickly without a lot of exchanges, but that's my approach to simply try to… Angiogram again, Selina? Oops. Maybe I can. There we go. Jeez. I might add a point on the guide selection beyond support. I mean, I think we all recognize this is a large preformed thrombus and thrombectomy may be involved, and I think the document highlights this a little bit, that some of the technique in doing thrombectomy is very relevant, and one of which is making sure the guide is very deeply engaged such that when you extract the thrombus, potentially the risks of losing that thrombus into the ascending aorta is minimized, so I think the guide choice for a number of reasons is wonderful. Yeah. I mean, you'd have to know how the wire felt going through to make sure you're in the right place rather than dealing with distal injections, et cetera. Sometimes imaging up front would be really helpful to understand the extent and distance and the size of this vessel. Great points. Okay. So we used a semi-compliant balloon and then did go ahead with manual thrombectomy with the priority one. No clot was retrieved, however, and the decision was made at this point to defer stenting. You can see a trickle of flow getting through there. I mean, fortunately with the end-stemming situation, the patient was probably stable or not experiencing... Yeah, stable, and we saw that robust collateral coming from the left, so the patient was placed on Tegrelin for 48 hours, dual antiplatelet therapy, including Ticagrelor, and the plan was to bring him back with another angiogram and the plan for stenting in 48 hours. This is what it looked like when he came back. Maybe before, Dr. Jha, can you go back to the angiogram with the thrombectomy? I think, Dr. Thomas-Holland, I'm just interested in your approach here, I mean, balloon, manual thrombectomy, mechanical aspiration, any thoughts on this, Dr. Thomas-Holland? It's interesting. It's definitely a hard call and I don't think there's going to be a right or wrong answer. This is why it's good I can answer this question. I think you have the luxury in a non-stemmy of stepping away, but let's say this was a stemmy and the patient still had an ongoing chest pain, I actually think your guide is really far down there. I would really like to try some more aspiration thrombectomy there, or, you know, the other thing is, you know, sometimes this does work, the artery is very big, and if you can just restore some flow to it with a very low pressure, small profile balloon, you're getting some flow in there and the body's intrinsic fibrolysis can potentially help there, but I probably would use aspiration here. Yeah, I think I would go for mechanical thrombectomy because the volume of the clot is so large and, you know, maybe use a continuous aspiration because I think you just lose the ability to – the manual aspiration is fairly limited in the amount in that you might have more risk of embolization. The other option, I mean, if you IVST and you had a good landing zone, very high risk for no reflow, but, again, sometimes trapping the thrombus behind a stent, a well-sized stent is an option. Yeah, no, I agree. You definitely want to do a continuous aspiration as opposed to a… Any comment on intracoronary pharmacology? Dr. Bartman, I know that – let's hear what you do because I know what you do. I've been known to give, you know, almost five figures of sodium nitroprusside in a single case. So, yeah, no, I think, you know, it's a tough case and I think we're all concerned – would be concerned about the implications of manipulating this lesion, this thrombus. If I were to, I think deferring if a patient's stable, recognizing that harm can be done to the established collaterals is really thoughtful. If we had to act or we felt compelled to act, I would definitely put something distally and kind of pre-medicate, pre-treat before any of those things. And I do agree with Dr. Abbott, I would do something pre-active thrombectomies. I would have started with manual thrombectomy as well, but I would have escalated if I was going to continue to act on this lesion. Would anybody use an angiojet? Yeah, we're using angiojet, but my understanding is that that's going off the market. Yeah, we don't have it in our lab anymore. I think since we've gotten the mechanical system, we've been using that. Well, talking about things going out of the cath lab, do you all have empty fibrotide? Yes. I don't think we carry empty fibrotide anymore. We may have trophobamine. Yeah. Well, Reapro has been off the market for a while, so it's one of the small molecules only. Dr. Young, do you want to show us what happens next? Sure. Yeah. And I think it was because the patient was stable and STEMI, not a STEMI scenario, that they had the luxury really of bringing him back. This is what it looked like, though, when he came back. Did you shoot the left? Are there good collaterals? Oh, yeah. Did you see in the beginning there were gigantic collaterals? Yeah. So, I mean, basically, you could see the whole PLPD system, which gave us this. That was the benefit in this scenario, probably why the patient was so stable, to be honest. So a couple of stents were laid down, large diameter, four and five, in the mid-to-distal vessel. The post-diabetics show an MF... Dr. Young, what we're saying, so direct stented, you just went down and direct stented this? You know, it was free... They had used a semi-compliant balloon before, so it wasn't completely direct stented. But all this opened up pretty nicely, and IVUS showed an MSA of 12. There was, as you can see at the very distal edge here, residual thrombus there. But the patient was stable. There was good flow down the vessel. I'm curious at this point what you guys would have done. Probably more thrombectomy, mechanical thrombectomy, or a low-pressure balloon and a lot of anticoagulation. Yeah. Just to make sure that there's... I would probably have left it alone, said you got great flow, looks good, give some IV GPIs and call it a day. But sorry, I didn't mean to interrupt it. I think it's just hard because you worry about stent thrombosis if there's not good outflow, and it looks like it's probably just propagated from the distal edge of the stent. So I think I would have tried a mechanical aspiration. Yeah. So we remember anecdotes, and of course, this is some of the challenges in this area is that sometimes there's not just much to guide. But I agree that it would be very tempted to do additional thrombectomy. Just literally recently, not long ago, I had a similar case, mechanical thrombectomy. We really sucked out a lot of clot. We did PCI stenting. We thought it had a good result. There's still a little bit of clot came back, not late afterwards, again, with stent thrombosis or with full clot, so yeah, all right. Oh, well, and this is what happened. So he went to the PACU, and a few hours later, had a post-procedure VF arrest. He was resuscitated with DC cardioversion. You can see now he's having a STEMI with the inferior ST elevations, reciprocal changes, and this is what it looked like, just proximal to the stent there. So, Priyanka, the thing is that the integrity of the distal circulation was okay because it was perfused by collateral flow. Now you open antigrade, and now you open the whole, all these clot and debris to go downstream. Yeah. Dr. Bartnik, any thoughts on what to do here? Well, you know, I'm just curious about this lesion that's a little bit upstream of your stent as well. I think you should image this and see if there's any identifiable cause, but it's possible that what's upstream is actually more severe than you think, angiographically. You may notice that if you eye this or OCT this. In this case, was it clopidogrel or ticagrelor? What was your antiplatelet agent? Ticagrelor. So first, they took a semi-compliant balloon and inflated it right at the lesion area, and then aspiration thrombectomy with Penumbra, and got out some fresh red thrombus, and kind of looks, at the end of that, back to where it was before. And the decision at this point was to continue the patient on 48 hours of heparin drip, integralin drip, and continue the aspirin ticagrelor. And that happened, and after that was over, the patient was chest pain-free the entire time, no BF, and was actually discharged home on DAPT. I like Dr. Bartnik's point, though. I think whenever you have stent thrombosis, it's really important to do intracoronary imaging because there could be a hematoma or something you're not recognizing based on the angiogram, or maybe your stent is not really expanded well. I think even though it looks angiographically well-expanded, I would have imaged just to make sure. And then the question is, I'm sure that half the people may have gone ahead and done some additional treatment of the distal thrombus, and I'm sure half would not. But this is why the document was written, because it is so difficult when you're making these decisions. A lot of times you don't have someone else around, you don't have a partner around, it's off hours. And so I think if you have TIMI 3 flow, and it's unclear what the next step should be, there's not necessarily a harm awaiting until it can be reviewed with multiple people, because you can always bring the patient back. But I think in this case, imaging would have been nice. It's interesting, they did do imaging after the stent was originally deployed. And that's when they got the MSA that looked good, the stent looked good, and then a few hours later is when the patient had the arrest. And then they did not do a second IVUS when he came back with the STEMI. Yeah, I guess they just figured it would have argued for another, or it could have been just the outflow problem. Yeah. Well, that was a great case. Thank you so much, Dr. Young. Sure. I pulled up here just the total and the TACE trials, just as a reminder of these 18,000 patients who were randomized to thrombectomy or PCI alone and didn't see a difference. And in fact, there was a small increase in stroke in the total trial. And so that led to the coronary revast guidelines giving a 3 recommendation for no benefit for thrombectomy. And I think this is kind of where the key points for our document really fill in the gaps because in bailout situations, aspiration thrombectomy would be an acceptable treatment strategy. And, of course, parenteral or IC agents could be used as well. All right. Thank you so much. I think we're going to skip this so we have time to go over to Dr. Cohen's presentation. You're going to be on fast forward here.

STEMI

thrombectomy

intracoronary imaging

dual antiplatelet therapy

VF arrest