Use of the Heartrail ST01 catheter for optimized aspiration thrombectomy in a patient with ST-segment elevation myocardial infarction with a large intracoronary thrombus

A 91-year-old woman presented with ST-segment elevation myocardial infarction (STEMI) after taking a meal. The emergent coronary angiography demonstrated acute proximal occlusion of the right coronary artery (RCA) (Figure 1 A). Initial aspiration thrombectomy (AT) with a Thrombuster II (Kaneka Medical) thrombus aspiration catheter (extraction area (EA) 0.95 mm2) recovered TIMI III flow. However, post-aspiration angiography demonstrated severe residual thrombus burden (Figure 1 B). Because of its large suction area, a guide extension mother-and-child catheter, Heartrail ST01 5 Fr (cross section area, CSA 1.77 mm2, Terumo Medical) catheter was positioned proximal to the site of the occlusion (Figure 1 C). Aspiration was performed with suction pressure generated by a 30 ml vacuum syringe and a larger and long embolus was sucked out (Figure 1 E), resulting in evident reduction of thrombus burden (Figure 1 D) and it was completed with a 3.5 × 30 mm zotarolimus-eluting stent (Endeavor, Medtronic) implantation. Histological examination showed thrombus with abundant infiltration of neutrophil (Figure 1 F). Furthermore, the patient received 100 mg of aspirin once daily and 90 mg of ticagrelor twice daily for 2 weeks, which was replaced by 100 mg of aspirin plus 75 mg of clopidogrel once daily with an 8-month follow-up to date and the patient has not suffered cardiovascular or bleeding events.
Despite improved clinical outcomes observed in early trials, recent randomized trials demonstrated that, in STEMI patients, as compared with percutaneous coronary intervention (PCI) alone, routine manual thrombectomy followed by primary PCI (PPCI) had no advantages in reduction of all-cause mortality, cardiovascular death, recurrent myocardial infarction, cardiogenic shock, or NYHA class IV heart failure but was associated with an increased rate of stroke [1]. Thus, routine thrombus aspiration is not recommended, but bailout in certain cases may be considered [2].
The success of manual aspiration is limited by multiple factors including catheter tip EA, vacuum generation, deliverability, and vessel and thrombus characteristics. A majority of PPCIs are performed through 6 Fr systems, and the greatest shortcoming is their small inner CSA (0.80 to 1.24 mm2). Moreover, utilizing 6 Fr guide systems markedly impeded the use of larger AT devices. Therefore, optimized AT with guide extension catheters seems to be a reasonable choice. In previous studies, guide...


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