Optical coherence tomography guided thrombectomy through a “home-made” aspiration catheter in a young patient with myocardial infarction. To stent or not to stent?

Introduction

Invasive coronary angiography (CA) is the traditional imaging modality for evaluation of the coronaries and guidance of percutaneous coronary intervention (PCI) during treatment of ST-segment elevation myocardial infarction (STEMI) [1]. However, CA provides just a two-dimensional luminography of the coronaries, without additional insights into plaque morphology, extent of atherosclerosis, thrombus burden and mechanisms of vessel occlusion [2].
The use of optical coherence tomography (OCT) delivers high-resolution images that accurately depict vessel and lesion characteristics, including the presence of thrombus, provides incremental assistance in stent implantation and minimizes stent-related issues [2]. OCT may also reveal the pathophysiology of arterial thrombosis, and optimize therapeutic options during PCI, especially in young patients where mechanisms of STEMI may vary [3].
Though plaque rupture remains the most common etiology of myocardial infarction (MI), in patients younger than 40–45 years unique syndromes such as plaque erosion, coronary microvascular dysfunction, spontaneous coronary artery dissection (SCAD), myocarditis, coronary embolism, hypercoagulable state and coronary spasm (drug related or not) are prevalent [3]. Consequently, intracoronary imaging is essential to clarify the underlying mechanisms when treating young MI patients, since stenting might not be the holy grail in this subgroup. Thrombus aspiration, though not routinely advocated by the guidelines, is required in selected patients for the recovery of coronary flow during primary PCI [1]. Previous reports have highlighted that in selected young patients presenting with STEMI, lone thrombus aspiration without balloon angioplasty or stenting is feasible and is associated with favorable short and long-term outcomes [4]. Dedicated thrombectomy catheters have been developed, but one size does not fit all anatomies, with some catheters being too small to accommodate a large thrombotic burden [5].

Aim

We report the case of a young patient who presented with anterior STEMI and underwent thrombectomy of a large free-floating thrombus through a “home-made” aspiration device, assembled from a guiding extension catheter and a guide catheter. OCT showed no signs of plaque rupture, allowing deferral of stent implantation.

Case report

A 38-year-old man, with positive family history for coronary artery disease, presented with...


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