title: Lesion-directed administration of alteplase with intracoronary heparin in patients with unstable angina and coronary thrombus undergoing angioplasty.
abstract: Percutaneous coronary revascularization in patients with unstable angina and coronary thrombus carries a high complication rate. A new strategy to reduce thrombus burden before revascularization was tested in a multicenter prospective trial. Patients with unstable angina and coronary thrombus (n = 45) received alteplase through an infusion catheter at the proximal aspect of the target lesion and concomitant intracoronary heparin via a standard guiding catheter. Angiography was performed before and alter lesion-directed therapy and post-intervention. Systemic fibrinogen depletion and thrombin activation were not observed, while fibrinolysis was evident for > or = 4 hr after treatment. Target lesion stenosis did not change significantly after lesion-directed therapy, but thrombus score was reduced, particularly among patients who had large thrombi (mean 2.2 vs. 1.6, P = 0.02). Revascularization was successful in 89% of patients. Median final stenosis was 30% and mean final thrombus score was 0.4. Complications included recurrent ischemia (11%), MI (7%), abrupt closure (7%), severe bleeding (4%), and repeat emergency angioplasty (2%). Patients with overt thrombus appeared to derive the most angiographic benefit from lesion-directed alteplase plus intracoronary heparin. Later revascularization was highly successful. This strategy may be a useful adjunct to percutaneous revascularization for patients with unstable angina and frank intracoronary thrombus.
authors.affiliation: Department of Medicine, University of Maryland Medical System, Baltimore, USA.
authors.forename: P A
authors.initials: PA
authors.lastname: Gurbel
authors.forename: F I
authors.initials: FI
authors.lastname: Navetta
authors.forename: E R
authors.initials: ER
authors.lastname: Bates
authors.forename: D W
authors.initials: DW
authors.lastname: Muller
authors.forename: A N
authors.initials: AN
authors.lastname: Tenaglia
authors.forename: M J
authors.initials: MJ
authors.lastname: Miller
authors.forename: B
authors.initials: B
authors.lastname: Muhlstein
authors.forename: J B
authors.initials: JB
authors.lastname: Hermiller
authors.forename: C J
authors.initials: CJ
authors.lastname: Davidson
authors.forename: F V
authors.initials: FV
authors.lastname: Aguirre
authors.forename: G J
authors.initials: GJ
authors.lastname: Beauman
authors.forename: L G
authors.initials: LG
authors.lastname: Berdan
authors.forename: J D
authors.initials: JD
authors.lastname: Leimberger
authors.forename: E G
authors.initials: EG
authors.lastname: Bovill
authors.forename: R H
authors.initials: RH
authors.lastname: Christenson
authors.forename: E M
authors.initials: EM
authors.lastname: Ohman
mesh_terms: D000328:Adult; D000368:Aged; D000789:Angina, Unstable / Q000000981:diagnostic imaging / Q000628:therapy*; D015906:Angioplasty, Balloon, Coronary / Q000295:instrumentation*; D003131:Combined Modality Therapy; D017023:Coronary Angiography; D003328:Coronary Thrombosis / Q000628:therapy*; D003402:Creatine Kinase / Q000097:blood; D004562:Electrocardiography; D004867:Equipment Design; D005260:Female; D005342:Fibrinolysis / Q000187:drug effects; D006493:Heparin / Q000008:administration & dosage*; D006801:Humans; D015552:Injections, Intralesional; D007527:Isoenzymes; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000000981:diagnostic imaging / Q000628:therapy; D011446:Prospective Studies; D015912:Thrombolytic Therapy / Q000295:instrumentation*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*; D016896:Treatment Outcome
chemical_list: D007527:Isoenzymes; D006493:Heparin; D003402:Creatine Kinase; D010959:Tissue Plasminogen Activator