Clot Management in Primary Percutaneous Coronary Intervention: Fighting Your Enemy

Abstract

Clot is often the enemy during primary percutaneous coronary intervention. Taking inspiration from the ancient wisdom of fighting a war, an interventionist should first look into the strength of the enemy, i.e. assess the thrombus burden, by both Thrombolysis in MI thrombus grade and angiographic features. This is to be followed by choosing the appropriate strategy: to attack – aspiration and mechanical thrombectomy; to surround – pharmacological therapy, including oral and parenteral antiplatelet therapy and intracoronary thrombolytic therapy; to avoid – stenting strategies including direct stenting and deferred stenting; to battle – stenting under a distal protection device or stenting across local obstructive thrombus; or to flee – to move from percutaneous coronary intervention to optimal antithrombotic therapy and circulatory support when flow fails to be regained. Of note, most of these strategies have not been demonstrated to be beneficial on routine use. The key remains to adopt different strategies selectively and appropriately in different scenarios.