Case 156: Manual of PCI - Large thrombus

A patient presented with an inferior STEMI and was found to have complete occlusion of a large dominant RCA. Diagnostic angiography was performed through right radial access but guide engagement was very challenging due to subclavian tortuosity. An AL1 and Ikari Right guide catheters kinked. Femoral access was obtained, but still engagement was challenging, and guide support was poor. After inserting a 45 cm long sheath and upsizing to a 7 French JR4 guide we successfully wired the RCA restoring TIMI 1 flow. Despite multiple passes with the Penumbra catheter, large thrombus remained within the RCA. We inserted a 6 French Guideliner Coast into the RCA and did aspiration through the side port of the tuohy removing several large thrombi. We then stented, that resulted in no reflow. Flow improved after intracoronary eptifibatide and nicardipine, that were given through the Penumbra catheter. We did IVUS and decided to not perform postdilatation to minimize the risk of recurrent distal embolization. The patient had an uneventful recovery.