Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3720_Библиотеки_им_академика_М_И_Перельмана

The significantly larger (n ¼ 2065) trial termed AIDA STEMI (Abciximab Intracoronary vs. Intravenous Drug Application in ST-Elevation Myocardial Infarction) compared IC bolus (via guide catheter) versus intravenous abciximab in patients with STEMI, and it showed no difference in the composite primary end point (all-cause mortality, recurrent infarction, or new congestive heart failure at 90 days: 7.0 vs. 7.6%; odds ratio 0.91; 95% CI 0.64e1.28; P ¼ .58) [18].A meta-analysis pooling the data from several trials also demonstrated no benefit from routine IC administration [19].Asof this writing, the evidence does not support routine use of IC abciximab in STEMI; however, using GP IIb/IIIa select receptor inhibitors as bailout therapy in the event of angiographic evidence of a large thrombus or slow or no reflow, and other thrombotic complications, is reasonable, as suggested by the latest guidelines [20]. It is worth highlighting, though, that at this writing, this strategy has not been tested in a randomized trial, and evidence supporting IC and locally directed therapy (i.e., via ClearWay catheter) is still needed. In this context, Case 1 represents the useful utilization of guideline recommendations for treatment with a GP IIb/IIIa platelet receptor antagonist in ACS. The 66-year-old patient presented with intermittent chest pain since completing a triathlon 2 weeks earlier. The past medical history was unremarkable aside from a family history of ischemic heart disease. The admission ECG demonstrated inferior T-wave inversion and serum troponin T was elevated. Coronary arteriography identified a proximally occluded right coronary artery (RCA) with organized thrombus (Fig. 11.1A). The left-ventricular function was preserved, with the left-ventricular angiogram demonstrating a viable inferior wall. Accordingly, an attempt to open the RCA was indicated. Despite wire escalation the procedure was abandoned with TIMI 1 flow and a decision made to treat with the GP IIb/IIIa platelet receptor antagonist eptifibatide for 24e48 h. Subsequent staged angiography demonstrated a patent RCA with TIMI 3 flow without any thrombus, but in the distal segment of the RCA a severe lesion was present (Fig. 11.1B). A 3.0  33-mm drug eluting stent (DES) was deployed with good result into the RCA proximal to the bifurcation of posterior descending artery (PDA) and posterior left ventricular branch of the right coronary artery (PLV).