Intracoronary Stent Deployment without Antiplatelet Agents in a Patient with Idiopathic Thrombocytopenic Purpura

Deciding on the appropriate antiplatelet therapy is a challenge when treating patients with idiopathic thrombocytopenic purpura (ITP) and who are undergoing percutaneous coronary intervention (PCI). We describe here a case of PCI in a patient with chronic, refractory ITP. A 61-year-old woman presented with exertional chest pain and a low platelet count (4 x 109/L) at admission. Coronary angiography revealed 99% stenosis of the mid left anterior descending artery and 95% stenosis of the mid left circumflex artery. Antiplatelet agents couldn't be administered because of the risk of bleeding. After transfusion of platelets and administering intravenous immunoglobulin, we deployed baremetal stents in both lesions without administering any antiplatelet agents. Although focal in-stent restenosis developed 5 months later, there was no episode of stent thrombosis despite not using antiplatelet agents. The present case suggests that the rate of stent thrombosis may be lower was previously thought and antiplatelet therapy may be considered on a case by case for patient suffering with thrombocytopenia.

Effect of Distal Protection Device on the Microvascular Integrity during Primary Stenting in Acute Myocardial Infarction: Distal Protection Device in Acute Myocardial Infarction

BACKGROUND AND OBJECTIVES: Phasic coronary flow velocity patterns and microvascular integrities are known to be prognostic factors in acute myocardial infarction (AMI). The use of a distal protection device during primary percutaneous coronary intervention (PCI) may preserve the microvascular integrity of the myocardium by preventing distal embolization of thrombotic materials. This study assessed the effects of such a device on microvascular integrity preservation through Doppler studies of the coronary flow velocities in AMI patients treated with primary PCI. SUBJECTS AND METHODS: A total of fifty-eight consecutive patients (mean age 54+/-15, 46 males) with ST segment-elevated AMI, who had undergone primary PCI within 24 hours after onset, were enrolled in the study. The subjects were divided into two groups: 30 patients with the PurcuSurge GuardWire Temporary Occlusion and Aspiration System and 28 without. The TIMI flows and TMP grades (TIMI myocardial perfusion grade) were evaluated. The coronary flow velocities were measured after PCI with a Doppler wire at the baseline, and also after intracoronary adenosine (24-48 microgram) induced hyperemia. The coronary flow velocity reserve (CFR), diastolic deceleration time (DDT) and microvascular resistance index (MVRI) were calculated. RESULTS: Between the two groups, no significant differences were found in the angiographic characteristics and CFR. In patients with a distal protection device, however, the post-PCI TMP grades were more favorable (TMP 0/1: 13.3%, TMP 2: 23.3%, TMP 3: 63.4% vs. TMP 0/1: 35.7%, TMP 2: 35.7%, TMP 3: 28.6%, p=0.023), with TMP grade 3 being most common (63.4% vs. 28.6%, p=0.010). These patients also exhibited lower bMVRI and hMVRI levels (4.33+/-2.22 vs. 5.55+/-2.36 mmHg.m-1.sec (p=0.047) and 2.39+/-1.40 vs. 3.14+/-1.36 mmHg.cm-1. sec (p=0.045), respectively), and longer bDDT and hDDT (679+/-273 vs. 519+/-289 msec (p=0.035) and 761+/-256 vs. 618+/-272 msec (p=0.044), respectively). CONCLUSIONS: Distal protection with the PurcuSurge GuardWire system may effectively preserve the microvascular integrity of the myocardium during primary PCI in AMI patients.