650 LARGE THROMBUS BURDEN: IS THERE STILL A ROLE FOR GPI?
Authors: Finocchiaro Simone , Mauro Maria Sara , Rochira Carla , Capodanno Davide , Tamburino Corrado 
Published: December 2022

Abstract

Background
A number of clinical trials documented clinical benefits of glycoprotein IIb-IIIa inhibitors (GPIs) in the setting of acute coronary syndromes (ACS). The advantage of reducing thrombotic burden at the cost of a higher risk of bleeding has been evaluated in different studies. However, data regarding the use of GPIs as peri-interventional treatment is lacking. Indeed, in current European guidelines GPIs may only be considered in specific ‘bail-out’ situations including high intraprocedural thrombus burden, slow flow, or no-flow with closure of the stented coronary vessel. The REPLACE-2 (Randomised Evaluation in PCI Linking Angiomax to Reduced Clinical Events 2) trial showed that the outcome with bivalirudin and provisional glycoprotein (GP) IIb/IIIa blockade is similar to that of UFH plus planned GP IIb/IIIa inhibition during PCI. Moreover, the use of GPIs as bridge to elective percutaneous coronary intervention (PCI) planned after unsuccessful urgent PCI in patients with NSTE-ACS has never been evaluated.

Clinical case
A 67-year-old man with multiple risk factors (hypertension, smoking and dyslipidemia) and history of coronary artery disease (CAD) was referred for acute chest pain and 27179 ng/L high-sensitivity-cardiac troponine (HS-cTn) at laboratory testing. The echocardiogram showed inferior and lateral wall hypokinesis with an inspective left ventricular ejection fraction (LVEF) of 40%. Therefore, the patient was conducted in the cath-lab and a coronary angiography was performed showing a thrombotic occlusion of proximal right coronary artery (RCA) due to a large thrombus burden. Then, an urgent PCI was indicated. Different guidewires was unsuccessfully attempted to pass throughout the lesion on the proximal segment of the vessel. Eventually, the patient was monitored in intensive care unit and it was decided to administer a continuous infusion of tirofiban for 48 hours to reduce the thrombus burden. During these two days an improvement of the clinical status, a reduction of HS-cTn and an increase in terms of LVEF were observed. At the end the patient underwent to new invasive coronary angiography that demonstrated significant changes of the thrombus burden translating into plaque modification. A PCI was attempted again. The guidewire reached the distal part of the RCA and 1 DES 3.5/28 mm was implanted with consequent optimal angiographic result.

Conclusion
In the era of potent and faster acting P2Y12-inhibitors like prasugrel and ticagrelor, the benefit and, more importantly, the safety of GPI, remains discussed. In the current European guidelines on revascularization, GPIs infusion should be considered for bail out with evidence of no-reflow or thrombotic periprocedural complication (Class IIa, level of evidence C). This clinical case shows the potential benefit of administrating GPIs as bridge to PCI in selected patients. Patients with an occluded infarct-related artery and large thrombus burden could benefit from GPIs infusion facilitating PCI.