Interv Akut Kardiol. 2024;23(1):43-49 | DOI: 10.36290/kar.2024.002

The role of intracoronary thrombolysis in thrombus-laden coronary artery: a case report

I Gde Rurus Suryawan¹, Rizal Muhammad², Fita Triastuti²

¹ Division of Interventional Cardiology, Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo Academic General Hospital, Indonesia

² Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo Academic General Hospital, Indonesia

Introduction: Large intracoronary thrombus in patients presenting with ST elevation myocardial infarction (STEMI) can cause distal embolization, the no-reflow phenomenon, and stent thrombosis. Approximately 10% of patients undergoing primary percutaneous coronary intervention (PCI) have distal embolization of thrombus, causing coronary microvascular obstruction and reduced myocardial tissue perfusion. This can lead to ongoing ischemia, a larger infarct size, and a significant increase in 30-day mortality, regardless of successful PCI with normal epicardial vessel flow.

Case Presentation: A 51-year-old Asian male presented with STEMI. Coronary angiography revealed a large thrombus totally occluding the proximal portion of the right coronary artery (RCA). Catheter-directed intracoronary thrombolysis with streptokinase was performed after multiple attempts at manual aspiration thrombectomy (MAT) and balloon angioplasty had failed to achieve coronary blood flow recovery. After successful stenting, a diffuse residual thrombus remained in the RCA. Evaluation angiography of the RCA performed four days later showed complete thrombus dissolution with thrombolysis in myocardial infarction (TIMI) grade 3 flow.

Discussion: While there is no gold-standard therapy to deal with intracoronary thrombus, there are combinations of both pharmacological and mechanical therapies that can be utilized. MAT should not be used routinely in STEMI, but may be helpful in selected cases. Catheter-directed intracoronary thrombolysis can be a safe and effective alternative reperfusion strategy when MAT alone fails to achieve sufficient coronary blood flow in the thrombotic infarct-related artery (IRA). 



Conclusion: The management of intracoronary thrombus during PCI remains a therapeutic challenge, and an aggressive, case-by-case, tailored approach can lead to improved outcomes.

Keywords: intracoronary streptokinase, manual aspiration thrombectomy (MAT), intracoronary thrombus, primary percutaneous coronary intervention (PCI), ST-elevation myocardial infarction (STEMI).

Received: October 25, 2023; Accepted: February 20, 2024; Published: April 29, 2024  Show citation