{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T11:03:45Z","timestamp":1789556625659,"version":"build-2803163510"},"reference-count":45,"publisher":"Wiley","license":[{"start":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T00:00:00Z","timestamp":1789516800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T00:00:00Z","timestamp":1789516800000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Cathet Cardio Intervent"],"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:p>High intracoronary thrombus burden complicates a significant proportion of ST\u2010segment elevation myocardial infarctions (STEMI) managed with primary percutaneous coronary intervention (PCI), and remains a major determinant of procedural complexity, microvascular obstruction, and adverse outcomes. Restoration of epicardial coronary flow alone does not ensure adequate myocardial reperfusion, as distal embolization and no\u2010reflow may occur despite technically successful PCI. Effective management requires an understanding of the dynamic interplay between thrombus burden, culprit plaque morphology, coronary flow, and procedural strategy. Although angiography remains the initial imaging modality, it frequently underestimates thrombus burden and provides limited information regarding the underlying lesion. Intravascular imaging offers complementary insights into thrombus composition, plaque morphology, vessel architecture, and lesion severity, facilitating tailored therapeutic decision\u2010making. Pharmacological treatment integrates potent antiplatelet and anticoagulant therapies, with selective use of intracoronary fibrinolytics and vasodilators in appropriate patients. Mechanical adjuncts, including aspiration thrombectomy, excimer laser coronary angioplasty, and emerging thrombus\u2010modifying technologies, may be beneficial in selected cases, although routine use has not consistently improved clinical outcomes. This review summarizes the contemporary evidence on the pathophysiology, assessment, and management of high thrombus burden in STEMI, highlights the complementary roles of angiography and intravascular imaging, and proposes a practical algorithm for individualized management based on coronary flow, thrombus characteristics, and culprit lesion morphology.<\/jats:p>","DOI":"10.1002\/ccd.70866","type":"journal-article","created":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T10:21:16Z","timestamp":1789554076000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["When the Clot Runs Deep: Tackling High Thrombus Burden in Primary Percutaneous Coronary Intervention"],"prefix":"10.1002","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0841-2969","authenticated-orcid":false,"given":"Bharat","family":"Khialani","sequence":"first","affiliation":[{"name":"Tan Tock Seng Hospital, National Healthcare Group Tan Tock Seng Singapore"},{"name":"Lee Kong Chian School of Medicine Nanyang Technological University Singapore Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eran","family":"Sim","sequence":"additional","affiliation":[{"name":"Tan Tock Seng Hospital, National Healthcare Group Tan Tock Seng Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-5132-4300","authenticated-orcid":false,"given":"George","family":"Touma","sequence":"additional","affiliation":[{"name":"St George Private Hospital Kogarah New South Wales Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah","family":"Fairley","sequence":"additional","affiliation":[{"name":"Wellington Hospital Wellington New Zealand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Umar","family":"Rashid","sequence":"additional","affiliation":[{"name":"Lenox Hill Hospital Northwell Health New York USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohammad","family":"Alkhalil","sequence":"additional","affiliation":[{"name":"The Newcastle Upon Tyne Hospitals NHS Foundation Trust Newcastle UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6165-7466","authenticated-orcid":false,"given":"Dharmaraj","family":"Karthikesan","sequence":"additional","affiliation":[{"name":"Hospital Sultanah Bahiyah Alor Setar Malaysia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Samuel","family":"McGrath","sequence":"additional","affiliation":[{"name":"Auckland City Hospital Auckland New Zealand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9346-8221","authenticated-orcid":false,"given":"Bernard","family":"Wong","sequence":"additional","affiliation":[{"name":"North Shore Hospital Auckland New Zealand"},{"name":"Faculty of Medical and Health Sciences School of Medicine, University of Auckland Auckland New Zealand"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,9,16]]},"reference":[{"issue":"2","key":"e_1_2_13_2_1","doi-asserted-by":"crossref","first-page":"125","DOI":"10.1161\/01.CIR.101.2.125","article-title":"Relationship of TIMI Myocardial Perfusion Grade to Mortality After Administration of Thrombolytic Drugs","volume":"101","author":"Gibson C. 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