A 69-year-old female patient presented to our emergency department experiencing chest pain, which she rated as an 8 on a scale of 10. The patient is a nonsmoker with a history of atrial fibrillation. Once admitted to the emergency room, she experienced one episode of vomiting. No shortness of breath or diaphoresis were present. The patient’s pain was slightly reduced by nitroglycerin. Laboratory tests were drawn and found to be the following: Troponin T = .1(< .03 normal), CPK = 131 (23-133 normal), CPK MB = 14 (0-6.5 normal), CK index = 10.7% (0-3.0% normal). The patient was started on heparin, aspirin, beta-blockers and nitroglycerin. An ECG demonstrated atrial fibrillation with no ST-segment elevation. Her pain was eliminated shortly after the medical therapy was initiated, however, this presentation was consistent with a myocardial infarction (MI), and she was taken to the cardiac catheterization laboratory for coronary angiography and possible intervention.
Catheterization was performed and showed that the left main artery was large and normal. Her left anterior descending artery was found to be widely patent with minimal irregularities. The patient’s diagonals and septals were intact and free of disease. Upon visualization of the circumflex artery, thrombus was discovered to be sitting in a bifurcation of the first obtuse marginal branch. Minimal distal filling was present, as well as coronary staining. Her second obtuse marginal was patent and her right coronary artery was dominant and normal, with brisk flow. Left ventriculography demonstrated a 55% ejection fraction.
Course of Action
Several approaches currently exist for the treatment of coronary thrombus. Our facility has successfully utilized the AngioJet® (Possis Medical, Inc., Minneapolis, Minnesota) device for the removal of thrombus in acute MI cases. We have also had success with the combination of stenting and glycoprotein IIb/IIIa agents, as well as stenting with filter basket wires. Our catheterization laboratory was recently exposed to a new thrombectomy device called Rinspiration (Kerberos Proximal Solutions, Inc., Cupertino, California), which involves simultaneous rinsing and aspiration of thrombus from the vessel. This vascular lavage device is relatively small and is held in one hand. Once the trigger is pulled, the tip of the catheter, which resembles a balloon catheter, lightly rinses the vessel wall and clot area while simultaneously aspirating the clot. The device is very lightweight and features two syringes that simultaneously inject saline and aspirate clot. Since the above-described patient was fairly stable, we considered her an ideal candidate for the use of this new technology.
This case presented a challenge due to the tortuous nature of the vessel. The obtuse marginal branch was very tortuous, with the thrombus located distal to the vessel and seated at a bifurcation. To our surprise, the catheter tracked very well and advanced to the area of thrombus on the first attempt. Once the catheter was positioned proximal to the thrombus, the operator completed four aspirations, moving forward with each. The catheter was removed from the vessel after the fourth aspiration. Follow-up angiography revealed complete removal of the thrombus, and complete restoration of flow. No residual plaque or thrombus were seen, and the flow and vessel results were so good that no stent was deployed. The vessel was only 2.75 mm in diameter, and was located distal to a bifurcation that precluded the use of the AngioJet device or stents. Upon inspection of the filter basket, we observed three different pieces of thrombus material trapped in the collection basket screen of the device.
We found the Rinspiration System to be highly effective. We put this catheter to the test in our patient’s tortuous vessel, and it advanced easily. The set up and preparation process were very quick and easy. The outcome showed complete evacuation of the thrombus and full restoration of flow. We were impressed with the simplicity and ease-of-use of the Rinspiration System and the excellent procedural outcome. The patient experienced no adverse side effects experienced with the use of this device.
We have only performed one case using the Rinspiration device. According to our local sales representative, we were the first in the city of Pittsburgh to utilize this technology. No long-term data exist for this approach to thrombus evacuation. Further data on and experience with this form of thrombus treatment must be examined to evaluate the efficacy of this device. Also, the device has not been compared to plain old balloon angioplasty or to other aspiration catheters.