Journal of the College of Physicians and Surgeons Pakistan 2009, Vol. 19 (12): 791-793 791 INTRODUCTION Primary percutaneous coronary intervention (PCI) is the preferred treatment for STEMI and is very effective in opening an infarct-related artery (IRA). However, microvascular obstruction resulting from embolization of plaque or thrombotic material results in sub-optimal myocardial reperfusion. 1 The high frequency of sub- optimal myocardial reperfusion after primary percutaneous coronary intervention (PCI) has resulted in the development of various devices to protect the microcirculation and improve myocardial reperfusion. Aspiration of intracoronary thrombus is an attempt to reduce thrombus burden in IRA and also to reduce chances of distal embolization. 2 This case report describes aspiration of a thrombus from right coronary artery through percutaneous intervention without stent placement. CASE REPORT A 48-year-old man; hypertensive, dyslipidemic presented in the emergency department with typical anginal chest discomfort of one hour duration associated with sweating. He had had a left sided ischemic cerebrovascualr accident 10 months back from which he had recovered completely. On arrival in the emergency department, he was hemodynamically stable and his cardiovascular examination was unremarkable. Electrocardiogram (EKG) showed 0.2 mV ST segment elevation in leads II, III, aVF with R wave and 0.1mV ST depression and upright-T wave in leads V1 and V2. 0.1 mV ST segment elevation was also present in lead V4R. EKG findings were consistent with acute infero-posterior ST elevation myocardial infarction (STEMI) with right ventricular infarction. He received standard STEMI protocol including 300 mg aspirin, 600 mg clopidogril, 5000 IU of unfractionated heparin intravenously and was started on glycoprotein IIb IIIA inhibitor, eptifibatide infusion after receiving weight adjusted double bolus with intention of primary percutaneous coronary intervention (PCI). He underwent diagnostic angiogram which showed complete occlusion of right coronary artery (RCA) in mid portion with large thrombus burden (Figure 1a). There was non-obstructive disease in left anterior descending and left circumflex arteries. A 6 Fr JR 4 guide was used to cannulate RCA. A 0.014"190 cm balanced middle weight wire (Guidant Corporation, Santa Clara-USA)) was advanced into distal right posteriolateral branch (RPLB). In view of the large thrombus burden an export aspiration catheter-6F (Medtronic, Inc. Minneapolis, USA) was advanced on the wire. Multiple runs of aspirations were made with removal of large thrombus (Figure 1b). The postaspiration angiogram showed restoration of thrombolysis in myocardial infarction (TIMI) III flow distally. Distal RPLB was occluded most likely secondary to embolization of thrombus (Figure 1c). Intracoronary nitropruside and adenosine were administered resulting in further improvement of flow. It was decided not to deploy a stent in mid RCA in view of the absence of any critical disease. He was started on GP IIb IIIa inhibitor (eptifibatide) infusion which had to be stopped a few hours later due ABSTRACT We are reporting the case of a 48-year-old man hypertensive, and smoker presenting with acute inferoposterior ST elevation myocardial infarction (STEMI) with right ventricular infarction. He underwent diagnostic angiogram which revealed total occlusion of mid right coronary artery (RCA) by thrombus. Multiple runs of aspiration were performed using Export Aspiration Catheter-6F and thrombus was aspirated from RCA. Postaspiration stenting was deferred due to absence of any significant obstructive lesion. Some thrombus had migrated to distal right posteriolateral branch (RPLB). He was started on glycoprotein (GP) IIb IIIa inhibitors which had to stopped after a few hours due to upper gastrointestinal bleed. After 48 hours a re-look angiogram demonstrated good flow in RCA with resolution of the residual thrombus. Key words: Myocardial infarction. Coronary artery. Thrombus. Percutaneous coronary intervention. Aspiration. Department of Cardiology 1 /Medical 2 , Tabba Heart Institute, Karachi. Correspondence: Dr. Ayaz Hussain Shaikh, Plot-140, Block-3, C.P. Berar Society, Karachi. E-mail: ahsdr1977@yahoo.com Received November 11, 2008; accepted September 26, 2009. Primary Percutaneous Coronary Aspiration of Thrombus from Infarct Related Artery Ayaz Hussain Shaikh 1 , Asad Pathan 1 , Khursheed Hasan 1 , Faiza Malik 1 , Hammad Ali Qazi 2 and Iqbal Mujtaba 2 CASE REPORT