The first reported aspiration thrombectomy with a guide extension mother-and-child catheter in ST elevation myocardial infarction due to bacterial vegetation coronary artery embolism

A 74-year-old man presented with ST elevation myocardial infarction (STEMI) on the 15th day of antibiotic therapy due to aortic valve staphylococcal endocarditis. The coronary angiography revealed occlusion of the left anterior descending artery (LAD) (Figure 1 A). Initial aspiration thrombectomy (AT) with an Export AP (Medtronic Vascular) catheter reestablished TIMI 3 flow. No trace of ruptured plaque was detected. However, the final contrast injection revealed occlusion of the left circumflex artery (LCx) (Figure 1 B), presumably by material translocated during withdrawal of the AT device. Since AT using the Export AP catheter was ineffective in the LCx, a guide extension mother-and-child catheter was applied as an aspiration device [1]. First a 2.0 × 20 mm balloon catheter was inflated beyond the site of the occlusion in order to ensure protection from distal embolism and facilitate the guide extension catheter advancement (Figure 1 C). Subsequently, the Heartrail II-ST01 5 Fr (Terumo Medical) catheter was positioned proximal to the site of the occlusion (Figure 1 C). Aspiration was performed with suction pressure generated by a 20 cc syringe attached to the proximal tip of the guide extension catheter via a y-connector, while the guide wire and balloon catheter remained at their positions. The large body of the embolus was pulled into the syringe (Figure 1 E), which resulted in TIMI 3 flow restoration (Figure 1 D). The patient’s further clinical course was uneventful. Histological examination of the aspirated material revealed thrombus with purulent foci, the picture suggestive of bacterial vegetation (Figure 1 F).
The greatest shortcoming of the dedicated aspiration catheters is their small inner cross-sectional area (CSA). The suction power is often insufficient to evacuate occlusive material, but intracoronary maneuvers may fragment it; therefore, distal embolization of the infarct related artery is a frequently reported complication [2]. Furthermore, a large thrombus or bacterial vegetation may get stuck at the tip of an aspiration device and be released during its withdrawal, causing embolic stroke or occlusion of another artery.
Frequently, the radial artery may not accommodate guide catheters larger than 6 Fr, which precludes the use of larger dedicated AT devices. Previously, in selected cases of STEMI, wherein a large thrombus not amenable to routine AT was identified, aspiration using a deeply advanced guide catheter or a...


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