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A 60‐year‐old man presented with a non‐ST‐elevation acute coronary syndrome. He had had a myocardial infarction 4 years before. Despite appropriate medical treatment, his chest pain continued and the electrocardiogram showed dynamic changes. He was transferred as an emergency from the district general hospital to the tertiary centre catheter laboratory.
Coronary angiography showed a normal left anterior descending artery and a small, chronically occluded circumflex artery. The right coronary artery was of enormous calibre and completely occluded with thrombus (panel A). The amount of thrombus was considerable, the calibre of the artery large and the vessel tortuous; so pharmacological dissolution was selected in preference to thrombectomy. A coronary guidewire was passed down the tortuous vessel with support from a probing catheter (Tracker, Boston Scientific). The tip of the Tracker was positioned in the middle of the thrombus. Tissue plasminogen activator (alteplase, 1 mg/ml saline) was injected by hand through the Tracker (10 mg bolus, followed by an infusion of 50 mg over 20 minutes). The thrombus completely dissolved distal to the Tracker (panel B). The Tracker was therefore withdrawn to a proximal vessel, and a further 20 mg infused over 10 minutes. The remaining thrombus disappeared and the underlying ulcerated, atherosclerotic plaque was disclosed (panel C). After the implantation of three stents of 4.5 and 5 mm diameter, the final appearance of the vessel was excellent (panel D). The patient was discharged home uneventfully 3 days later.
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