الفهرس 
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Abstract
Percutaneous coronary intervention (PCI) has emerged as the strategy of choice for re-establishing effective flow in occluded infarct-related arteries in patients with acute coronary syndromes especially those have ST elevation myocardial infarction (STEMI).
While immediate PCI is often the preferred strategy in this situation, The thrombus related angiographic complications (no or slow flow or distal embolization) is still observed in large percentage of patients after primary PCI, and is associated with incomplete ST segment resolution, increased necrosis volume and poor outcome with increase in 5-year mortality.
The basic principle of delayed stenting approach is to attempt to restore in emergency a TIMI grade 2 or 3 flow in the infarct-related artery then to perform stent implantation in more stable conditions (after period of intense antithrombotic burden) to decrease the risk of stenting-induced no flow and distal embolization.
Study design:
The study included 53 patients with TIMI flow II or III (obtained either sponta¬neously or after manual aspiration and/or balloon dilatation of an occluded coronary artery) subjected to either immediate or deferred stenting according to discretion of the operator;
- Immediate stenting (IS) group: included thirty patients with the stent implanted immediately in presence of thrombotic burden ,
- Deferred stenting (DS) group: twenty three patients with the stent implanted after period of intense antithrombotic therapy.
GPIIb IIIa was used in all DS group while only patients with major thrombotic complications in IS group are received it.
Then the patients subjected to
- Full medical history, clinical examination and different lab investigations included cardiac biomarkers.
- Baseline and follow up echocardiography at 3 month.
- Both immediate and deferred PCI are compared as regard;
i. Periprocedural angiographic events.
ii. Bleeding complications.
iii. In hospital ischemic events.
iv. Major adverse cardiac events (MACEs) at 3 month.
- Influence of antithrombotic therapy on angiographic features in patients with deferred PCI.
Results:
- Stenting was performed less frequently in the delayed stenying group than in the immediate stenting group, because of the angiographic improvement in lesion characteristics (100%vs.70%, P=0.001).
- Stent diameter was more and stent length was less in delayed stenting group, however, this is not statistically significant (P=0.389 &0.509 respectively).
- The thrombus-related angiographic events (no or slow flow or distal embolization) was observed more in the IS group in comparison with the DS group; (33 % vs. 13%, P= 0.089 ). Patients who develops slow or no flow had certain angiographic features; i) initial higher thrombus burden ii) there was initial abrupt cutoff pattern without taper before the occlusion iii) Less TIMI II flow before stent implantation .
- The enhanced antithrombotic therapies increased neither major nor moderate bleeding as compared with the immediate stenting, minor bleeding was nearly similar in both groups ((8.6% vs. 3.3%, P=0. 0.687) .
- No major adverse cardiac events were observed in the 2 groups during both the initial hospital stay and during the waiting period (between initial coronary angiogram and deferred PCI) in the delayed stenting arm.
- At 3-month follow-up, no differences were noted in terms of cumulative major adverse cardiac events ( death, reinfarction and TVR) between the 2 study groups (10% vs. 8.7%, P=0.624)
- At three months follow up there was a statistically significant positive correlation between pre and 3 month EF% in both groups and improvement was statistically significant (P=0.001). However, the degree of the improvement in ejection fraction in the DS group was not significantly larger than that of the IS group (P=0.21).
- Patients assigned to DS group; after GPIIb IIIa infusion, the thrombus burden score is significantly decreased from 3.78 + 0.42 to 2.57 + 0.945 (P=0.001) and TIMI flow is significantly improved from 2.69+0.47 to 2.97+0.21 (P=0.011) owing to the enhanced effect of the potent antiplatelet GP IIb IIIa in thrombus resolution. Also the culprit lesion length is significantly decreased from 27.44 +7.46 to 23.38+6.65 (P=0.011).