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This case describes a patient who developed non-ST elevation myocardial infarction during hospitalization for acute hypoxic respiratory failure due to COVID-19. We review the immediate and delayed revascularisation strategies of culprit and non-culprit lesions in the setting of high intracoronary thrombus burden induced by SARS-CoV-2. Successful percutaneous intervention and stenting of a culprit lesion and resolution of an intracoronary thrombus using a delayed strategy of lesion passivation with adjuvant pharmacotherapy are demonstrated on index and follow-up angiography.<\/jats:p>","DOI":"10.1136\/bcr-2021-246223","type":"journal-article","created":{"date-parts":[[2021,12,7]],"date-time":"2021-12-07T11:20:46Z","timestamp":1638876046000},"page":"e246223","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Approach to high intracoronary thrombus burden in the era of COVID-19"],"prefix":"10.1136","volume":"14","author":[{"given":"Kevin M","family":"Coy","sequence":"first","affiliation":[{"name":"Cardiology, University of South Dakota, Sioux Falls, South Dakota, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Andrii","family":"Maryniak","sequence":"additional","affiliation":[{"name":"SUNY Downstate Medical Center Department of Internal Medicine, Brooklyn, New York, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Thomas","family":"Blankespoor","sequence":"additional","affiliation":[{"name":"Sanford School of Medicine, University of South Dakota, Sioux Falls, South Dakota, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Adam","family":"Stys","sequence":"additional","affiliation":[{"name":"Sanford USD Medical Center Department of Cardiology\u2014Sioux Falls, Sioux Falls, South Dakota, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2021,12,7]]},"reference":[{"key":"2025082712490539000_14.12.e246223.1","doi-asserted-by":"crossref","DOI":"10.1016\/j.cpcardiol.2020.100744","article-title":"A review of coronary artery thrombosis: a new challenging finding in COVID-19 patients and ST-elevation myocardial infarction","volume":"46","author":"Kermani-Alghoraishi","year":"2021","journal-title":"Curr Probl Cardiol"},{"key":"2025082712490539000_14.12.e246223.2","doi-asserted-by":"crossref","first-page":"1031","DOI":"10.1161\/CIRCULATIONAHA.120.051828","article-title":"Microthrombi as a major cause of cardiac injury in COVID-19: a pathologic study","volume":"143","author":"Pellegrini","year":"2021","journal-title":"Circulation"},{"key":"2025082712490539000_14.12.e246223.3","first-page":"272","article-title":"Acute myocardial infarction and large coronary thrombosis in a patient with COVID-19","volume":"97","author":"Tedeschi","year":"2021","journal-title":"Catheter Cardiovasc Interv"},{"key":"2025082712490539000_14.12.e246223.4","doi-asserted-by":"crossref","DOI":"10.1093\/eurheartj\/ehaa393","article-title":"Multivessel coronary thrombosis in a patient with COVID-19 pneumonia","volume":"41","author":"Dominguez-Erquicia","year":"2020","journal-title":"Eur Heart J"},{"key":"2025082712490539000_14.12.e246223.5","doi-asserted-by":"crossref","first-page":"1289","DOI":"10.1093\/eurheartj\/ehaa575","article-title":"2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation","volume":"42","author":"Collet","year":"2021","journal-title":"Eur Heart J"},{"key":"2025082712490539000_14.12.e246223.6","doi-asserted-by":"crossref","first-page":"B10","DOI":"10.1093\/eurheartj\/sux043","article-title":"Timing of intervention in non-ST segment elevation myocardial infarction","volume":"20","author":"Banning","year":"2018","journal-title":"European Heart Journal Supplements"},{"key":"2025082712490539000_14.12.e246223.7","doi-asserted-by":"publisher","DOI":"10.1161\/hc0502.102867"},{"key":"2025082712490539000_14.12.e246223.8","doi-asserted-by":"crossref","first-page":"e08","DOI":"10.15420\/ecr.2020.31","article-title":"Deferred stenting for heavy thrombus burden during percutaneous coronary intervention for ST-elevation MI","volume":"16","author":"Pradhan","year":"2021","journal-title":"Eur Cardiol"},{"key":"2025082712490539000_14.12.e246223.9","unstructured":"Sharma J . Facing the intracoronary thrombus burden: the two-step approach to coronary stenting. Cath lab digest, 2013. Available: https:\/\/www.cathlabdigest.com\/articles\/Facing-Intracoronary-Thrombus-Burden-Two-Step-Approach-Coronary-Stenting [Accessed 24 Apr 2021]."},{"key":"2025082712490539000_14.12.e246223.10","doi-asserted-by":"crossref","unstructured":"Sathananthan J , PJL O , Khoo D . Management of Intracoronary Thrombus. In: Watson TJ , PJL O , Theng JE , eds. Primary angioplasty. Singapore: Springer, 2018: 345\u201396.","DOI":"10.1007\/978-981-13-1114-7_10"},{"key":"2025082712490539000_14.12.e246223.11","doi-asserted-by":"crossref","first-page":"95","DOI":"10.15420\/icr.2019.11","article-title":"Thrombus embolisation: prevention is better than cure","volume":"14","author":"Choudry","year":"2019","journal-title":"Interv Cardiol"},{"key":"2025082712490539000_14.12.e246223.12","unstructured":"Adnan G , Singh DP , Mahajan K . Coronary Artery Thrombus. In: StatPearls. 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