• Images in cardiology

A 55 year old male patient without previous cardiac history underwent coronary angiography because of angina pectoris (Canadian Cardiovascular Society class 3) and a positive exercise test. The right coronary artery and left anterior descending artery showed only mild irregularities, but the mid right circumflex (RCX) artery showed a luminal filling defect suggestive of thrombus just proximal to a severe stenosis (panel A). Left ventricular function was normal. The procedure was ended and it was decided to perform percutaneous coronary intervention of the RCX after 24 hours of pre-treatment with a glycoprotein IIb/IIIa inhibitor. However, only minutes after completion of the procedure the patient complained of severe chest pain. Repeat angiography showed an occluded RCX (panel B). It was noted that a sidebranch to the left atrium was now visible whereas it was not on the previous film, suggesting embolisation of a previously occluding thrombus. Immediate angioplasty of the RCX was performed, resulting in distal embolisation and no reflow (panel C), without any improvement after intracoronary papaverine. Subsequently, a thrombectomy device (Rescue catheter, Boston Scientific) was used in an attempt to remove thrombotic material and improve coronary flow. A red, organised thrombus (6 × 2 mm) was removed (lower panel). The final result of the procedure showed TIMI 3 flow and grade 3 myocardial blush (panel D). Maximum creatine kinase-MB was 29 μg/l, and left ventricular ejection fraction was 68% after two months.

This case illustrates one of the less frequent mechanisms of acute myocardial infarction—namely, embolisation of a coronary thrombus. Thrombus formation may have occurred due to turbulent flow just proximal to a severe stenosis.