Management of the thrombotic lesion

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Percutaneous coronary intervention Microchapters


Patient Information


Risk Stratification and Benefits of PCI

Preparation of the Patient for PCI

Equipment Used During PCI

Pharmacotherapy to Support PCI

Vascular Closure Devices

Recommendations for Perioperative Management–Timing of Elective Noncardiac Surgery in Patients Treated With PCI and DAPT

Post-PCI Management

Risk Reduction After PCI

Post-PCI follow up

Hybrid coronary revascularization

PCI approaches

PCI Complications

Factors Associated with Complications
Vessel Perforation
Distal Embolization
Coronary Vasospasm
Abrupt Closure
Access Site Complications
Peri-procedure Bleeding
Renal Failure
Late Acquired Stent Malapposition
Loss of Side Branch
Multiple Complications

PCI in Specific Patients

Cardiogenic Shock
Left Main Coronary Artery Disease
Refractory Ventricular Arrhythmia
Severely Depressed Ventricular Function
Sole Remaining Conduit
Unprotected Left Main Patient
Adjuncts for High Risk PCI

PCI in Specific Lesion Types

Classification of the Lesion
The Calcified Lesion
The Ostial Lesion
The Angulated or Tortuous Lesion
The Bifurcation Lesion
The Long Lesion
The Bridge Lesion
The Chronic Total Occlusion
The Left Internal Mammary Artery
Multivessel Disease
Distal Anastomotic Lesions
Left Main Intervention
The Thrombotic Lesion

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


The presence of angiographically apparent thrombus is associated with poorer outcomes in patients undergoing PCI. Thrombus often embolizes distally and causes no reflow and associated myonecrosis. There are two broad strategies to reduce thrombus burden: mechanical strategies and pharmacologic strategies.

Management of The Thrombotic Lesion

Differentiating Thrombus from Other Angiographic Abnormalities

Goals of Treatment

Goals in the management of the thrombotic lesion include:

Step-By-Step Strategy in the Management of the Thrombotic Lesion

Pharmacologic Therapy

Antiplatelet Therapy

Antithrombin Therapy

Thrombolytic Therapy

Mechanical Therapy

Thrombus Aspiration

Direct Stenting

Distal Protection

  • Distal Protection can be achieved with the following devices (Percusurge guardwire, Triactive, Spider wire, Proxis), particularly in saphenous vein grafts
  • Occlusive (Percusurge guardwire, Triactive) and filter (Filterwire) methods may improve safety and efficacy of PCI in patients with thrombotic lesions in SVG; SAFER study of Percusurge device demonstrated lower rate of death/MI
  • Distal embolic protection has not shown to be efficacious in the setting of STEMI in native coronary arteries with either Percusurge (EMERALD trial)[2] or Filterwire (PROMISE trial).[3]

Rheolytic Thrombectomy

Less Frequently Used Modalities

  • Directional Atherectomy
  • Transluminal Extraction Catheter (TEC)

Management of No Reflow

Distal embolization of thrombus often occurs, and you should be prepared to treat the patient for potential spasm or no-reflow with a calcium channel blocker, adenosine (100 mcg IC) or nitroprusside (100 mcg IC).


  1. White HD, Braunwald E, Murphy SA; et al. (2007). "Enoxaparin vs. unfractionated heparin with fibrinolysis for ST-elevation myocardial infarction in elderly and younger patients: results from ExTRACT-TIMI 25". Eur. Heart J. 28 (9): 1066–71. doi:10.1093/eurheartj/ehm081. PMID 17456482. Unknown parameter |month= ignored (help)
  2. Nikolsky E, Stone GW, Lee E; et al. (2009). "Correlations between epicardial flow, microvascular reperfusion, infarct size and clinical outcomes in patients with anterior versus non-anterior myocardial infarction treated with primary or rescue angioplasty: analysis from the EMERALD trial". EuroIntervention. 5 (4): 417–24. PMID 19755327. Unknown parameter |month= ignored (help)
  3. Gick M, Jander N, Bestehorn HP; et al. (2005). "Randomized evaluation of the effects of filter-based distal protection on myocardial perfusion and infarct size after primary percutaneous catheter intervention in myocardial infarction with and without ST-segment elevation". Circulation. 112 (10): 1462–9. doi:10.1161/CIRCULATIONAHA.105.545178. PMID 16129793. Unknown parameter |month= ignored (help)

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