P306 MANAGEMENT OF MASSIVE EMBOLIZATION OF STRATIFIED THROMBUS FROM A CORONARY ANEURYSM: A CASE OF MUTUAL CAMOUFLAGE

Abstract Introduction We report the intraprocedural, post–procedural management and long–term therapeutic strategy in a case of an acute coronary syndrome caused by occlusion of a posterior interventricular branch (IVP) originating from a segment of the right coronary artery with a normal diameter, but, affected by an aneurysm with an extensive stratified thrombotic formation that embolized during the procedure. Case description: 47–year–old man, a heavy smoker, comes to the emergency room about 24 hours after the onset of constant chest pain. ECG: basically, within the limits. Echocardiogram: mild concentric hypertrophy. Mild infero–basal hypokinesia. Blood tests: troponin 355 pg/ml –> 854 pg/ml (pre–coronarography). On coronary angiography, occlusion of the interventricular branch posterior to the ostium originates from a segment of the right coronary artery of apparently normal diameter. The angioplasty procedure caused the mobilization of extensive parietal thrombotic formation adhering to the distal section of the right coronary artery and in the proximal section of the posterior atrioventricular branch with massive embolization of the posterolateral branches, revealing the presence of a coronary ectasia in the same site, not visible before thrombus mobilization. Discussion The goal of intraprocedural management was to obtain reperfusion of the embolized branches by numerous passages of the manual thromboaspirator and numerous balloon inflations on the embolized branches, without placing stents. The antithrombotic therapeutic strategy was dual antiplatelet therapy (DAPT) with acetylsalicylic acid/ticagrelor 90 mgx2, Tirofiban in the first 12 hours and anticoagulation with enoxaparin (8000 IUx2). Conclusions Coronary angiography at 7 days showed complete disappearance of residual thrombotic formations. The choice of long–term pharmacological strategy was only DAPT with an extension program of over 12 months with ticagrelor 60x2 even though the Pegasus criteria were not present.