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Cardiac Computed Tomography for Detecting Intracoronary Thrombotic Structures in Proximal LAD Bare Metal Stents

Anger Thomas, Bender Bernhard, Plachtzik Claudia, Oberhoff Martin, Höher Martin

Anger Thomas, Plachtzik Claudia, Oberhoff Martin, Department of Cardiology, Division of Medicine, Klinikum Calw-Nagold, Germany
Bender Bernhard, Höher Martin, Department of Cardiology, Division of Medicine II, Klinikum Bayreuth, Germany

Correspondence to: Thomas Anger, Department of Cardiology, Division of Medicine, Innere Medizin/ Kardiologie, Klinikum Calw-Nagold, Kliniken Calw, Eduard Conz Straße 6, D-73511 Calw, Germany.
Email: th.anger@arcor.de
Telephone: + 49-07051-14-41130
Fax: +49-0-7051-14-42195
Received: July 14, 2014
Revised: January 25, 2015
Accepted: January 26, 2015
Published online: February 10, 2015

ABSTRACT

Thrombus distribution is known part of atrial arrhythmias. We here report a clinical example using cardiac 256-multidetector row computed tomography (256 MDCT) for examination to assess for small intracoronary thrombotic structures in proximal parts of vessels with either big size (> 2,5 mm diameter) and/ or existing bare metal stents on a 70 years old male individual. He was suffering a non ST elevated myocardial infarction due to intracoronary thrombus in bare metal stents in the proximal left artery descending (LAD) in regard to occult atrial fibrillation. Philips 256 iCT documented the small amount of rest thrombus after abciximab pre treatment before discharge of the patient under acetylsalicylacid (100mg) and phenprocoumon (for 6 months). Summarised, this example proposes and underlines further use of cardiac MDCT for patients with acute chest pain to improve prognostic outcome by reduction of complications. Additionally, even 3 years after bare metal stent implantation in big vessels, here proximal LAD, we are mainly demonstrating the need of continuous antithrombotic acetylsalicylacid treatment to avoid in-stent thrombosis.

Key words: Cardiac 256-MDCT; Intraluminal Bare Metal Stent Thrombus; Acetylsalicylacid; Abciximab

© 2015 The Authors. Published by ACT Group Ltd.

Anger T, Bernhard B, Claudia P, Martin O, Martin H. Cardiac Computed Tomography for Detecting Intracoronary Thrombotic Structures in Proximal LAD Bare Metal Stents. Journal of Cardiology and Therapy 2015; 2(1): 269-272 Available from: URL: http://www.ghrnet.org/index.php/jct/article/view/1034

Learning Objective

Further use of Cardiac CT is the detection of intraluminal thrombotic material in coronary stents.

case report

A 70 years old male patient in good health conditions with known coronary artery disease and existing three bare-metal stents (Cobalt-Chronium “Multi-Link Vision Bare-Metal Coronary Stent System, 3.0×12mm, Abbott, Wiesbaden, Germany) in the proximal and mid part of the left anterior descendents artery (LAD) implanted 3 years ago, was presented to the Department for Cardiology with acute chest pain for 2 hours following chemically a Non-ST-Elevated Myocardial Infarction (NSTEMI).

In the past, a common drug treatment was established with 100 mg acetylsalicylacid per day, 2.5 mg bisoprolol per day, 10 mg ramipril per day, 20 mg simvastatin per day and for 4 weeks clopidogrel 7 5mg per day after bare-metal stent-implantation. The 100 mg acetylsalicylacid treatment was discontinued due to an elective surgery on the right carotid artery interna 2 weeks before hospital presentation in regard to severely stenosis.

Actually, the Troponin I level raised to 1.5 ng/mL (normal < 0.05ng/mL) and the ECG demonstrated an paroxysmal atrial fibrillation turning in normal ventricular frequency (to this date unknown). Immediately, an invasive coronary angiography was performed and the coronary status was assessed revealing a remarkable structure in the proximal two stents of the LAD suspected to an intracoronary thrombus while normal perfusion was determined in all stents and the rest of the vessel (TIMI 3), see figure 1 (pre, marked through white arrows).

Due to an intraluminal reduction of only 30% Diameter Stenosis in both proximal LAD stents, abciximab adjusted to the body weight was given intravenously for 12h and a second look was assessed using Philips iCT Cardiac 256-MDCT while the patient spontaneously converted into normal sinus rhythm (Figure 2). Retrospective gating to 75% RR interval was performed (heart rate 65 beats per minute) and only a small rest thrombus in the proximal LAD stent surrounded by non- and calcified plaques as well as the struts of the both “Vision” stent systems (only 0.0032" thick) were observed (see bold white arrow, figure 2). The complete vessel demonstrated further almost inconspicuous perfusion. Caused through additional unspecific symptoms of the patient, we performed a second invasive coronary angiography with complete normal perfusion in all LAD stents (proximal and mid) and ruled out further intravascular thrombotic materials, see figure 1 (post).

The patient got discharged 2 days later set on Phenprocuomon for 6 months due to stable sinus rhythm improved by beta-receptor inhibition (metoprolol 95 mg per day) added to 100 mg acetylsalicylacid per day.

Discussion

While thrombus distribution is known part of atrial arrhythmias[1-4], this example reveals cardiac 256-multidetector row computed tomography (256 MDCT) as clinical examination to explore small intracoronary thrombotic structures in proximal parts of vessels with either big size (> 2,5 mm diameter) and/or existing bare metal stents[5].

The thrombotic structure in the LAD stents is caused through the discontinuing of 100 mg per day acetylsalicylacid treatment. The obviously distribution of the thrombotic material in the vessel is focusing mainly in the stent regions which excludes coronary embolisms through atrial arrhythmias as reason for the intraluminal thrombus.

We support a further use of cardiac CT detecting intraluminal thrombotic material following (1) coronary calcium scoring[6], (2) coronary plaque formations[7-9], (3) coronary artery disease[10,11], (4) left ventricular function (mass, regional wall motions, ejection fraction)[12,13], (5) right ventricular function[14], (6) valve function (aortic valve)[15], and (7) the detection of the culprit lesion in myocardial infarction[16-18].

Infusion of abciximab as antithrombotic treatment regimen is part of the drug management in acute coronary symptoms[19-22]. Here, partial success for thrombus lysis was assessed detected through cardiac 256-MDCT while even complete thrombus abolishment was assumed using conventional invasive coronary angiography (see figure 1, lower panel.).

This example proposes and underlines further use of cardiac MDCT for patients with acute chest pain to improve prognostic outcome by reduction of complications[23]. Additionally, even 3 years after bare metal stent implantation in big vessels, here proximal LAD, we are mainly demonstrating the need of continuous antithrombotic acetylsalicylacid treatment to avoid in-stent thrombosis.

CONFLICT OF INTERESTS

There are no conflicts of interest with regard to the present study.

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Peer reviewer: Wilbert S Aronow, Cardiology Division, New York Medical College, Macy Pavilion, Room 138, Valhalla, NY 10595, USA; Christopher X. Wong, Research Fellow, Clinical Trial Service Unit, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, England.

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