A novel triple-device recanalization strategy combining a small-diameter balloon, guide extension catheter, and distal protection device for large thrombus-induced coronary artery occlusion: a case report

Large intracoronary thrombus during primary PCI for ST-elevation myocardial infarction (STEMI) remains challenging, particularly when aspiration techniques fail. We report a novel mechanical retrieval technique using balloon-assisted locking between a guide extension catheter and a distal protection device, enabling en bloc thrombus extraction.

An 80-year-old man presented with inferior STEMI due to total occlusion of the proximal right coronary artery. Repeated aspiration attempts failed to retrieve the thrombus. A previously described guide extension catheter–distal filter device technique failed due to filter migration into the guide extension. A small-diameter balloon was positioned between the Guidezilla II and Filtrap and inflated to create a stable mechanical coupling, which enabled the successful removal of a large thrombus and restoration of TIMI 3 flow.

This balloon-assisted modification addresses a key mechanical limitation of earlier hybrid techniques—proximal migration of the Filtrap into the Guidezilla II during device withdrawal, likely due to pulling forces and device size mismatch. The balloon stabilizes and captures the thrombus between the guide extension catheter and the balloon, enabling controlled en bloc retrieval of the thrombus. This approach may reduce distal embolization risk and may help avoid stent implantation in thrombus-laden segments during revascularization in selected patients.