Management of the thrombotic lesion

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editors-In-Chief:

Goals of Treatment

There are several main goals in treating thrombotic lesions, including:

• Reperfusion of the epicardial artery and the downstream microvasculature
• Resolution/reduction of thrombus burden
• Avoid/minimize distal embolization
• Avoid/reduce thrombotic major adverse cardiac events (death, MI, recurrent ischemia, urgent target vessel revascularization (TVR))

Treatment Choices

Pharmacologic Therapy

• Antiplatelet therapy: Aspirin, platelet glycoprotein IIb/IIIa receptor (GP IIb/IIIa) antagonists (abciximab, eptifibatide, tirofiban), ADP receptor/P2Y12 inhibitors (plavix, ticagrelor, prasugrel)

• Antithrombin Therapy: Ufractionated heparin (UFH), low molecular weight heparin (LMWH). Fondaparinux is not recommended in primary PCI.

• Direct Thrombin Inhibitors: Hirudin, bivalirudin, argatroban

• Thrombolytic Therapy: Urokinase (UK), tissue plasminogen activator (tPA) for STEMI when other pharmacologic and mechanical treatments are not successful

Mechanical Therapy

• Aspiration Catheter: (Export, Pronto) is the choice prior to the other interventions listed below

• Percutaneous Coronary Intervention (PCI): Bare metal or drug-eluting stent particularly direct stenting without pre-dilation by conventional balloon angioplasty

• Distal Protection: (Percusurge guardwire, Triactive, Spider wire, Proxis) particularly in saphenous vein grafts

• Percutaneous Transluminal Coronary Angioplasty (PTCA)

• Directional Atherectomy

• Transluminal Extraction Catheter (TEC)

• Rheolytic Thrombectomy (Possis Angiojet)