Author + information
- Received July 22, 2015
- Accepted August 13, 2015
- Published online December 28, 2015.
- Milosz Jaguszewski, MD, PhD,
- Brunilda Alushi, MD, PhD,
- Leif-Christopher Engel, MD and
- Juan Luis Gutiérrez-Chico, MD, PhD∗ ()
- Interventional Cardiology Department, Charité Medical University, Campus Benjamin Franklin, Berlin, Germany
- ↵∗Reprint requests and correspondence:
Dr. Juan Luis Gutiérrez-Chico, Interventional Cardiology Department, Charité Medical University, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany.
- aspiration thrombectomy
- intimomedial abrasion
- optical coherence tomography
- primary percutaneous coronary intervention
A 73-year-old man referred for primary percutaneous coronary intervention (pPCI) presented with complete occlusion of the proximal left anterior descending artery (LAD) (Online Video 1). Aspiration thrombectomy was performed with an Export AP catheter (forward-facing tip, 1.09-mm inner lumen diameter, 1.73-mm outer diameter; Medtronic Cardiovascular, Santa Rosa, California), thus removing a red thrombus (Figure 1) and restoring distal Thrombolysis In Myocardial Infarction grade III flow. Milking (i.e., muscular bridge) was then observed in the mid-LAD (Online Video 2). After stent implantation in the proximal LAD, the ST-segment leveled out and chest pain remitted. However, 5 mins later and before sheath removal, chest pain relapsed with transient recurrent ST-segment re-elevations. Repeat angiography found only a slightly hazy region around the milking segment (Online Video 3). Optical coherence tomography (OCT) revealed an intracoronary structure proximal to the milking segment, with high optical backscattering and low attenuation, attached to the vessel wall by a filiform proximal pedicle (Figures 2A and 2B) in direct continuity with a proximal intimomedial abrasion (Figure 3). These OCT findings suggested the intracoronary mass to be a pediculated intimomedial flap versus a white thrombus as the differential diagnosis, so a second careful aspiration was performed and the mass was successfully removed (Figure 1). A final OCT scan confirmed removal and absence of new iatrogenic lesions (Figure 2C). Milking shows a regular oval shape of the 3 vascular layers in the first pullback (obtained in systole) (Figure 4A), absent in the corresponding matched cross sections in the second pullback (obtained in diastole) (Figure 4B).
The optical properties of the intraluminal mass and the clinical course strongly suggest an intimomedial flap abraded during thrombectomy, attached to the wall by a distal filiform endothelial pedicle and everted distally into the lumen. This flap might cause recurrent transient ischemia via a valvular mechanism. A white thrombus might have a similar macroscopic appearance and optical properties (1,2), but the relatively regular contour and the thickness gradient (thicker distally than proximally) do not support this differential diagnosis. Milking might have increased the risk of intimomedial abrasion due to dynamic reduction of the vessel caliber (Figures 2B and 2C).
For supplemental videos, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 22, 2015.
- Accepted August 13, 2015.
- American College of Cardiology Foundation
- Tearney G.J.,
- Regar E.,
- Akasaka T.,
- et al.