Is there still a place for thrombectomy?

Malignancy is known to be a prothrombotic condition, and some antitumor drugs may amplify the hypercoagulable tendency. We present a female patient with cancer, who developed acute coronary syndrome (ACS) due to occlusive intracoronary thrombus without underlying atherosclerosis.
A 59-year-old woman with metastatic breast cancer diagnosed 2 years ago, paraneoplastic syndrome and steroid diabetes was admitted to our institution due to chest discomfort. The patient was previously treated with chemotherapy (trastuzumab and methylprednisolone). The last course was administered 4 months ago. The antithrombotic treatment with enoxaparin had been discontinued 3 weeks before, when an intensive rehabilitation program for cerebellar syndrome was initiated. Based on ST-segment depression in V4–V6 leads in ECG and elevated troponin T up to 2923 ng/ml (UNL < 14), non-ST segment elevation myocardial infarction (NSTEMI) was diagnosed. Coronary angiography did not show any vessel wall irregularities. However, occlusive thrombus in the distal segment of the right coronary artery (RCA) was visualized, with distal TIMI 1 flow (Figures 1 A, B). 5000 IU of unfractionated heparin was administered, manual thrombectomy was performed (Figure 1 C) and the TIMI 3 flow was restored (Figure 1 D). After successful thrombus evacuation there was no RCA stenosis on angiography. Thus, neither balloon angioplasty nor stenting was attempted. Echocardiography revealed akinesis of the inferior wall, modestly impaired left ventricular systolic function with ejection fraction of 50% and moderate mitral regurgitation secondary to perforation of the posterior mitral leaflet (probably old), which was decided to be left for conservative treatment. Antithrombotic treatment with 75 mg of clopidogrel and 1 mg/kg o.d. of enoxaparin was prescribed indefinitely.
Breast cancer may itself induce a hypercoagulatory state, which can subsequently lead to thrombus formation within the venous system, pulmonary circulation, and more rarely within different arteries. Antithrombotic prophylaxis with low-molecular-weight heparin (LMWH) is recommended, and its withdrawal for any reason may exacerbate the hypercoagulable tendency.
The role of thrombectomy as an adjunctive tool for primary percutaneous coronary intervention after ambivalent results of the four main randomized trials [see insightful comments of Musiałek [1] on the limitations of these studies] remains uncertain. Surprisingly, neither...


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