Asian Cardiovasc Thorac Ann 2003;11:269-271
© 2003 Asia Publishing EXchange Ltd
Use of Excimer Laser for Thrombus Containing Lesion
Erdogan Ilkay, MD,
Ilgin Karaca, MD,
Mustafa Yavuzkir, MD,
Özlem Gündo
du, MD,
Nadi Arslan, MD
Firat Medical School, Department of Cardiology, Elazig, Turkey
For reprint information contact: Erdogan Ilkay, MD Tel: 90 424 2388019 Fax: 90 424 2388019 email: ilkayerdogan{at}superonline.com Zübeyde Hanim Cad.116/6, Elazig, Turkey.
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ABSTRACT
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The presence of thrombus in the lesion before balloon angioplasty increases the complications arising from mechanical intervention. It is known that the use of Gp llb/llla receptor blockers before the intervention enhances the reliability of the procedure. Laser thrombolysis was applied to a patient who underwent coronary angiography due to recurrent chest pain after thirty six hour administration of tirofiban and who was found to have a thrombus so large as to block the distal vessel bed of the right coronary artery. Following the procedure, the entire thrombus was broken down and Grade III distal myocardial perfusion was achieved. This case is important in demonstrating that laser application is a viable alternative in such instances, especially considering that intervention in acute coronary syndromes is on the increase and cardiologists will frequently encounter such cases.
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INTRODUCTION
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The presence of thrombus in the lesion before balloon angioplasty increases the complications arising from mechanical balloon dilatation.1 It has been reported that making use of low molecular weight heparin and more recently Gp llb/llla receptor blockers before the intervention in acute coronary syndromes enhances the reliability of the procedure.2,3 In this case, a laser was applied to a thrombus so large as to clog the distal vessel bed despite Gp llb/llla receptor blockers. The patient was sent to our center for coronary angiography due to recurrent chest pain and was administered tirofiban for 36 hours upon the diagnosis of non-ST elevation myocardial infarction (NSTEMI).
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CASE REPORT
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A male 47 year old patient was admitted to the hospital due to rest pain that had begun two days previously. The TnT level of the patient was found to be 1.3 ng•ml-1. Electrocardiography (ECG) showed T-inversion in inferior deviations. The patient was diagnosed as NSTEMI, and a course of tirofiban, unfractioned heparin, acetyl salicylate and clopidogrel was commenced. As the heart rate was 45 bpm sinus and the patient was not taking beta blockers, 10 mg of transdermal nitroglycerin was also administered. During the follow-up Activated Clotting Time (ACT) was maintained at about 230 seconds. The patient was sent to our center for emergent coronary angiography upon the recurrence of his chest pain after 36 hours.
The ECG revealed D2, D3, T-inversion at a VF, biphasic T wave in V1-3. The heart rate was 49 bpm sinus rhythm and blood pressure was 130/90 mm Hg. The patient had no risk factors except for hyperlipidemia and ACT at 245 seconds, TnT at 2.1 ng•ml-1. The echocardiography showed the left ventricle ejection fraction to be 54%, the posterior and inferior wall as hypokinetic with 1° mitral regurgitation.
Coronary angiography: The intervention was made from the right femoral artery. Temporary pace lead was placed at the right ventricle apex from the left femoral vein as the patient had bradycardia during chest pain attacks. In the coronary angiography, the left main artery, left anterior descending and circumflex artery were normal. Right coronary artery was entered by 6F Guiding catheter (Cordis, Johnson and Johnson). Right coronary angiography showed a lesion in the middle segment, 13 mm in length causing a 95% obstruction and just in its distal a 2 x 1.9 mm thrombus. Distal flow was TIMI-II (Figure 1A
). The size of the thrombus was so that it clogged the distal bed. Since there was a high risk of embolisation of the thrombus to the distal bed during balloon angioplasty, it was decided to employ a laser. After the lesion was crossed by a 0.014 inch guide-wire, 3 cc opaque was administered slowly. It was seen that there was no embolisation of the thrombus (Figure 1B). The lesion was treated with laser energy 11 times by 0.9 OS laser catheter at 45 mj•mm-2, 25 Hz (Figure 1C). A Spectranetics CVX-300 laser pulsed light (308nm) Excimer laser system was used as the laser source (Spectranectics, Colorado Springs). The delivery of laser energy featured safe lasing techniques4 (saline injections during laser activation and 0.5 ml•sec-1 advancement through the lesion) and ‘pulse and retreat’ lasing technique.5 This consisted of retrieving the laser catheter from the irradiated lesion and into the guiding catheter after every two laser trains, 1–2 ml•sec-1. Saline infusion was continued during the procedure. After the lasing procedure it was observed that the thrombus disappeared and that distal coronary bed flow was myocardial Grade-III (Figure 1D). 3.5–16 mm (Helistent-HexacatH-France) stent was deployed at 12 atmospheres (Figure 1E). TIMI-III flow and Grade III myocardial perfusion were ensured after the procedure. Gp llb/llla receptor blocker was continued for 24 hours following procedure. Low molecular weight heparin was applied subcutaneously.
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DISCUSSION
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Mechanical balloon dilatation in lesions that include thrombus leads to the dislocation of the thrombus and causes severe thromboembolisation.1 This results in myocardial perfusion disorder with no reflow phenomenon or TIMI-III flow. It has been reported that Gp llb/llla receptor blockers reduce this risk.3 Therefore the use of Gp llb/llla receptor blockers before intervention in high-risk cases is recommended.3 Various methods have been put forward for thrombotic lesions. However in this case application of distal protection devices could have led to the distal embolisation of the thrombus during the passage of filter (Angioqugard-Johnson-Johnson) or balloon guide wire (PercuSurge-AVEMedtronics).6 A thrombectomy catheter such as the ‘Rescue’ catheter or the ‘Export’ catheter (from PercuSurge) could have been used to remove the thrombus. Alternatively either X-sizer or laser could be chosen.7,8 The laser was preferred in this instance because of past experience.
Laser application is relatively new. The first cases were presented by Topaz et al. and a 80–90% reduction in thrombus load was reported.8–10 Excimer laser induced fibronolysis occurs in part due to the mechanical effects of propagating acoustic waves which destroy the mesh fibrin fibers.11,12 The laser forms explosive gas bubbles within the hemoglobin which dissolve the clot by forming acoustic waves in the structure of the clot.12 Moreover, laser treatment has inhibitory effects on platelet adhesion.11
In thrombotic lesions, a laser may ensure vaporization of the thrombus when a catheter of smaller diameter size is used and when the thrombus is larger than the catheter in volume. As such, a 0.9 mm laser catheter was used in this instance. This case shows the successful treatment of a thrombus that persisted despite administration of Gp llb/llla receptor blockers. It is thought that this case is important in demonstrating that laser application is a viable alternative in such instances, since the need for intervention in acute coronary syndromes is increasing gradually and interventional cardiologists will frequently encounter such cases.
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REFERENCES
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- White CJ, Ramee SR, Collins TJ, Escobar AE, Karsan A, Shaw O, et al. Coronary thrombi increase PTCA risk. Angioscopy as a clinical tool. Circulation 1996;93:253–8.[Abstract/Free Full Text]
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ABSTRACT
Introduction
