Case Report


Figure 1: Posterior–Anterior Caudal View of the Left Coronary System Before Treatment


The American Heart Hospital Journal


distal left main stem (LMS) stenosis with two large filling defects involving the proximal left anterior descending artery (LAD) and the large intermediate vessel (see Figure 1). Spontaneous intracoronary dissection was also considered as a potential diagnosis.


A management plan was needed to deal with the thrombus in this patient’s LMS, proximal LAD, and intermediate vessel. The cardiac surgeons were consulted and, as the patient was hemodynamically stable with no ongoing chest pain, a joint decision was made to treat him with an intravenous abciximab (a glycoprotein IIb/IIIa receptor blocker) bolus followed by a 12-hour infusion.


Intracoronary thrombus is seen in the distal left main stem (LMS) extending to the proximal left anterior descending artery (LAD; arrow) and large intermediate vessel (IM1).


Figure 2: Posterior–Anterior Caudal View of the Left Coronary System After Treatment with Abciximab and One Week of Treatment with Dual Antiplatelet Therapy


A repeat diagnostic angiography performed one week later showed almost complete resolution of the thrombus within the distal LMS with some residual thrombus adhering to the outer aspect of the origin of the LAD. The intermediate vessel appeared completely free of any thrombus (see Figure 2). IVUS performed at the same time showed soft plaque extending from the distal LMS into the origins of both the LAD and the intermediate vessels, with evidence of rupture of the plaque at the origin of the LAD (see Figure 3). At this point there was some residual thrombus as well as some organized fibrous plaque. The patient received further treatment with abciximab. Diagnostic angiography a few weeks later showed the coronary arteries to be free of any thrombus (see Figure 4).


Discussion


In our case, the possible management strategies were percutaneous coronary intervention, peripheral IV thrombolysis, intracoronary thrombolysis, coronary thrombectomy, manual thrombus aspiration, and even coronary artery bypass surgery. A thrombectomy catheter was not used as there was a possibility of spontaneous intracoronary dissection, which would have increased the risk of passing the coronary guidewire distally in the vessel. He was therefore managed conservatively with triple antiplatelet therapy of aspirin, clopidogrel, and abciximab.


Acute myocardial infarction in young adults may have multiple causes.4


However, there must be a high index of


Residual thrombus is seen in the proximal left anterior descending artery (LAD). IM1 = intemediate vessel; LMS = left main stem.


126


suspicion for intracoronary thrombosis in patients who abuse anabolic steroids. This case report highlights the successful treatment of myocardial infarction with a large intracoronary thrombotic burden in one such case using triple antiplatelet therapy. This is the first reported case of extensive LMS thrombus in a young patient with anabolic steroid abuse. The management of such cases is not straightforward and our case highlights one approach to both diagnosis and treatment. n


Intravascular Ultrasound and Angiographic Demonstration of Left Main Stem Thrombus Winter 2010


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