Primary left main coronary artery thrombus aspiration as a standalone treatment: sailing in uncharted waters

Introduction

Left main coronary artery thrombosis (LMCAT) identified during coronary angiography is a rare and challenging condition. The following case report describes the use of the thrombus aspiration technique, as a lone therapy for LMCAT, in the setting of ST-segment elevation myocardial infarction (STEMI) and reviews current data regarding this therapeutic approach.

Case report

A 49-year-old patient, a heavy smoker with untreated dyslipidemia and no other apparent risk factors for coronary artery disease, was admitted to the emergency room with retrosternal burning chest pain. During physical examination the patient was symptomatic but hemodynamically stable, and ECG was consistent with acute STEMI. The bedside cardiac triplex revealed a left ventricle of normal dimensions with segmental akinesia of the apex and the apical anterior wall with a normal right ventricle. The existence of aortic aneurysm or dissection was also ruled out.
The patient was immediately transferred to the coronary unit for primary percutaneous coronary intervention (PCI). The examination was performed using a right transradial approach and revealed the presence of a mobile structure within the left main coronary artery (LMCA) that partially compromised the coronary flow in the left anterior descending and left circumflex arteries (LAD, LCX), while the right coronary artery (RCA) appeared normal (Figures 1 A, B). The LMCA angiographic finding resembled a thrombus; therefore manual aspiration was performed with a STENTYS aspiration catheter (Brage Medical, France), while the patient received concomitantly intravenous bivalirudin. After the guidewire apposition at the distal part of the LMCA, the aspiration catheter was guided to the proximal part of the thrombus and manual aspiration was performed at a rate of 1 ml per second using a lockable syringe (Figure 1 C). After advancing the aspiration catheter several times through the thrombotic lesion the aspirated material was emptied to a filtered basket in order to isolate the thrombotic particles (Figure 2 A). Immediate reexamination of the LMCA revealed thrombus resolution and restoration of Thrombolysis in Myocardial Infarction (TIMI) flow III in both the LAD and LCX (Figure 2 B).
The patient was transferred to the coronary intensive care unit in an asymptomatic and hemodynamically stable condition, while ST elevation subsided after the thrombus resolution. Troponin I peak measurement was...


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