Long and Massive Thrombus in the Left Coronary Artery: A Case of Acute Myocardial Infarction Treated Using Immediate Stenting and Direct Oral Anticoagulant Plus Dual Antiplatelet Therapy.

Background: Managing massive thrombi in the coronary arteries of patients with acute myocardial infarction presents considerable challenges, and the effectiveness of immediate versus deferred stenting as a treatment option remains uncertain. Moreover, it is unclear whether dual antiplatelet plus direct oral anticoagulant therapy is more effective for massive thrombi in the coronary arteries than dual antiplatelet therapy alone. We report the case of a patient with acute myocardial infarction with a long and massive thrombus in the left anterior descending artery treated with an immediate stenting strategy and antithrombotic combination therapy. Case Presentation: A 90-year-old female presented with a chief complaint of chest depression due to a long and massive thrombus in the left anterior descending artery with associated acute myocardial infarction. Immediate stenting to cover the ruptured plaque and trap the massive thrombus without encountering slow flow/no-reflow phenomenon, and employing thrombolysis through a combination of antiplatelet agents and a direct oral anticoagulant resulting in sustained coronary blood flow during the transition from the acute to subacute phases, led to favorable procedural and clinical outcomes. Conclusions: If immediate stenting with thrombolysis using a direct oral anticoagulant plus dual antiplatelet agents is successful without distal embolism, this strategy could be a better treatment than deferred stenting in terms of preventing periprocedural cardiac adverse events and reducing healthcare costs. Furthermore, dual antiplatelet agents plus direct oral anticoagulant combination therapy are considered to suppress platelet function and fibrin generation strongly, leading to the disappearance of thrombus.