Cardiovasc Interv and Ther DOI 10.1007/s12928-015-0323-7
Coronary thrombus aspiration revealed tumorous embolism of myxofibrosarcoma from the left atrium Masamitsu Noguchi • Yoko Yamada • Kenichi Sakakura • Takuji Katayama Shin-ichi Momomura • Junya Ako
Received: 12 January 2015 / Accepted: 12 February 2015 Ó Japanese Association of Cardiovascular Intervention and Therapeutics 2015
Abstract Thrombus aspiration is currently the standard strategy for primary PCI. Thrombus can be aspirated via aspiration catheters, restoring coronary blood flow. However, there are a limited number of reports regarding thrombus aspiration toward tumor embolized occlusion. We present a case of 90-year-old male with AMI caused by the metastatic tumor embolism. Emergent coronary angiography revealed total occlusion in three epicardial vessels. Histopathological examination of the aspirated specimen revealed the mixture of thrombus and metastatic tumor cells. Thrombus aspiration was partially effective for restoring coronary blood flow; however, it was very helpful for the final diagnosis of tumor embolism.
because of the large amount of thrombi . Furthermore, it is very difficult to differentiate tumor embolized occlusion from thrombus occlusion following intimal plaque rupture at the time of primary PCI. Thrombus aspiration is currently the standard strategy for primary PCI [4, 5]. Thrombus can be aspirated via thrombectomy catheters, restoring coronary blood flow . However, there are a limited number of reports regarding thrombus aspiration toward tumor embolized occlusion. We present a case of 90-year-old male with AMI caused by the metastatic tumor embolism. Thrombus aspiration was partially effective for restoring coronary blood flow and was helpful for the definitive diagnosis of tumor embolism.
Keywords Acute myocardial infarction Tumor embolism Thrombus aspiration
Introduction Acute myocardial infarction (AMI) caused by coronary tumor embolism is rarely observed, but potentially lethal [1, 2]. Primary percutaneous coronary intervention (PCI) for AMI caused by tumor embolism can be complicated
M. Noguchi and Y. Yamada contributed equally to this article. M. Noguchi Y. Yamada K. Sakakura (&) T. Katayama S. Momomura J. Ako Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan e-mail: [email protected]
J. Ako Department of Cardiovascular Medicine, Kitasato University School of Medicine, Kanagawa, Japan
A 90-year-old man was admitted to our hospital because of acute ST-elevation myocardial infarction (Killip Class III). He had a history of myxofibrosarcoma in the right upper arm. The electrocardiogram showed ST segment elevation in lead I, aVL, and V2 to V5 with reciprocal changes in lead II, III, and aVF (Fig. 1a). Initial creatine kinase (CK) and CK-MB were 1505 and 173 U/L, respectively, and Trop T test (TROP T sensitive, NIHON KOHDEN, Tokyo, Japan) was positive. The chest X-ray showed bilateral congestion and multiple round masses in the right lower lung field and left middle lung field (Fig. 1b). Transthoracic echocardiography revealed a large tumor on the left atrial septum, along with akinesis of the anterior wall as well as akinesis of the lateral wall of the left ventricle (Fig. 1c). Aortic valve disease (stenosis or regurgitation) was not detected by echocardiography. Emergent coronary angiography revealed total occlusion in the proximal segment of left anterior descending artery (LAD), the proximal
M. Noguchi et al. Fig. 1 a Electrocardiogram shows ST elevation in I, aVL, and V2-5 leads. b Chest X-ray shows bilateral congestion and multiple round mass in the right lower lung field and left middle lung field. c Transthoracic echocardiogram shows a large mass on the left atrium septum
Fig. 2 a Emergent coronary angiography revealed total occlusion in the proximal segment of LAD (arrow), the proximal segment of LCX (arrow), and the proximal segment of ramus intermedius artery (arrow) (RAO-caudal view). b While thrombus aspiration recanalized LCX and ramus intermedius arteries, which yielded TIMI-3 grade flow in each vessel, thrombus aspiration failed to recanalize LAD (arrow)
segment of left circumflex artery (LCX), and the proximal segment of ramus intermedius artery (Fig. 2a). We discussed with cardiovascular surgeons about treatment strategy including atrial tumor. Since multiple round masses suggested metastatic tumors from myxofibrosarcoma, curative open heart surgery for atrial tumor was not indicated
even if the patient did not suffer from acute myocardial infarction. We discussed with patient’s family, and decided to perform primary PCI for the purpose of pain relief. An intra-aortic balloon pump was inserted via the left femoral artery to stabilize his cardiogenic shock, and a 7 Fr JL3.5ST guiding catheter (Mach 1, Boston Scientific, Natric, MA,
Coronary thrombus aspiration
USA) was inserted via the right femoral artery. Three conventional guidewires easily passed the occluded lesions of LAD, LCX, and ramus intermedius arteries. Thrombus aspiration was performed to each occlusion, using a conventional thrombectomy catheter (Rebirth Pro, Goodman, Nagoya, Aichi, Japan). The inner lumen diameter of aspiration catheter was 1.25 mm. While thrombus aspiration recanalized LCX and ramus intermedius arteries, which yielded TIMI-3 grade flow in each vessel, thrombus aspiration failed to recanalize LAD (Fig. 2b). Aspirated specimen appeared milky white substance, which were quite different from conventional thrombus. Since it was getting more difficult to keep patient’s rest position in the catheter laboratory, we did not try to perform additional procedures such as ballooning or stenting. The patient was admitted to the coronary care unit following primary PCI; however, he suddenly died due to cardiac rupture 4 h after PCI. Although we could not obtain an informed consent to perform full autopsy from the patient’s family, we could submit aspirated specimen to the department of pathology for the histopathological investigation. Histopathological examination of the aspirated thrombus revealed the mixture of thrombus and tumor cells, which were characterized by spindle-cell proliferation with moderate cellular density in the fibromyxoid stroma. (Fig. 3a; fibromyxoid stroma, * thrombus). Immunohistochemical examination also confirmed the diagnosis of myxofibrosarcoma, which were compatible with his right arm tumor. Because the histology of the aspirated thrombus was very similar to the histology of his right arm tumor, we assumed that the myxofibrosarcoma in the left atrium, which was considered to be the metastasis from the right arm tumor, was the origin of coronary artery thromboembolism.
Discussion In present case, thrombus aspiration was partially effective for treating multiple tumor embolisms. While LAD could not be recanalized in spite of multiple attempts of aspiration, two of three occluded arteries restored TIMI-3 grade flow. Moreover, thrombus aspiration was very helpful to make a definite diagnosis in the situation that full autopsy was not available. As compared with tumor embolism in cerebral artery , tumor embolism in coronary artery is rare, because of the anatomy of coronary angle and the protection by the aortic valve cusps . In most cases, the embolism comes from left-sided tumors such as myxomas because of its fragility. Although left atrial myxomas are the most common source of neoplastic embolism, the incidence of coronary embolism in patients with myxomas is reported to be very low (0.06 %) , which makes it difficult to establish standard therapeutic strategy for coronary tumor embolism. Furthermore, AMI caused by tumor embolism is associated with high mortality rate , partly because tumor embolism can occur in multiple vessels at the same time  as shown in the present case. There are several case reports of AMI caused by tumor embolism [9–15]. Although the conservative therapy was chosen in old cases [10–14], PCI was performed in recent cases [9, 15]. Kumagai et al.  tried to recanalize the occluded vessel by performing plain old balloon angioplasty (POBA), but failed to restore blood flow. Steiner et al.  reported the usefulness of thrombectomy catheter for the diagnosis of carcinoma embolization in coronary artery, although they did not describe the details of procedures. In the present case, aspiration of occluded emboli was successful in two
Fig. 3 a Aspirated material from thrombectomy catheter. b High magnification image of boxed area in a. spindle-cell proliferation and pleomorphism of the nucleus with moderate cellular density in myxoid stroma. * hematoma
M. Noguchi et al.
of three occluded vessels, but was unsuccessful in the LAD. Our case suggests the possibility and limitation of thrombectomy catheter for the treatment of embolic coronary occlusion. Unlike thrombus following intimal plaque rupture or common coronary embolism due to atrial fibrillation, as a tumor embolus might not be dissolved or fragmented, mechanical removal by thrombectomy catheter would theoretically be promising as compared to balloon angioplasty. However, aspiration catheter may not work for a large embolus because the lumen diameter of conventional aspiration catheters is less than 2 mm, which is supposed to be smaller than the diameter of large emboli. Another possible aspiration procedure is direct aspiration by guiding catheter [16–18]. Direct aspiration by guiding catheter may need additional devices and techniques such as 4 Fr multipurpose catheter for 5 Fr direct aspiration , mother–child technique , or DIO (Goodman, Nagoya, Aichi, Japan) . Although we could not perform intravascular ultrasound (IVUS), imaging modalities such as IVUS or optical coherence tomography may help interventionalist to choose appropriate procedures including stenting. On the other hand, our case suggests the definite usefulness of thrombectomy catheter for the diagnosis of embolic coronary occlusion. Only direct aspiration of embolic specimen in occluded vessels allows us to explore the histopathological examination without autopsy. In conclusion, we experienced a case of AMI caused by tumor embolism. Thrombus aspiration was partially effective for recanalization, whereas aspirated specimen was helpful for making the definitive diagnosis.
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