The role of intracoronary thrombolysis in selected patients presenting with ST-elevation myocardial infarction: a case series

BACKGROUND: Primary percutaneous coronary intervention (PCI) is the cornerstone of management for ST-elevation myocardial infarction (STEMI). However, large intracoronary thrombus burden complicates up to 70% of STEMI cases. Adjunct therapies described to address intracoronary thrombus include manual and mechanical thrombectomy, use of distal protection device and intracoronary anti-thrombotic therapies. CASE SUMMARY: This series demonstrates the use of intracoronary thrombolysis in the setting of large coronary thrombus, bifurcation lesions with vessel size mismatch, diffuse thrombosis without underlying plaque rupture, and improving coronary flow to allow vessel wiring and proceeding to definitive revascularization. DISCUSSION: Larger intracoronary thrombus burden correlates with greater infarct size, distal embolization, and the associated no-reflow phenomena, and propagates stent thrombosis, with subsequent increase in mortality and major adverse cardiac events. Intracoronary thrombolysis may provide useful adjunct therapy in highly selected STEMI cases to reduce intracoronary thrombus and facilitate revascularization.