The challenge of intracoronary thrombus burden should first be met by incorporation and utilization of contemporary thrombus classifications and their recent modifications. Preferably, all clinical procedures involving percutaneous coronary intervention in acute coronary syndromes should assess and report the presence of thrombus in the targeted lesions and vessels. Intravascular thrombus adhering to an underlying atherosclerotic plaque impairs flow dynamics and represents a considerable obstacle for the safety and effectiveness of revascularization. Plaque disruption and subsequent thrombosis are recognized as critical processes contributing to the onset of acute coronary ischemic syndromes. The merit of the new reclassification extends beyond the original application for AMI, and this method can be used in all encounters of grade 5 thrombus in patients with ischemic coronary syndromes. Options for the task vary from rheolytic thrombectomy to X-Sizer or excimer laser and subsequent stenting, preferably, again, with a thrombus-capturing stent. The larger size clot requires a dedicated mechanical thrombectomy device for removal. In most instances a stratified small-grade thrombus can be managed with an aspiration catheter followed by implantation of a thrombus-capturing stent or with pharmacologic agents. This intervention re-establishes a certain degree of antegrade coronary flow to the extent that the exposed underlying thrombus can undergo restratification into either a small thrombus burden (grade 1–3) or a large thrombus burden (grade 4) with treatment ensuing accordingly (Figure 2). Their method utilizes either a guide wire or a 1.5 mm balloon for crossing and recanalization of the target thrombus. Focusing on this specific grade, they added a much needed critical step to the reclassification that significantly improves the determination of the correct load of the underlying thrombus ( Box 2). Thus, in order to overcome the abovementioned limitation of TIMI grade 5, an important modification was recently introduced by the Thoraxcenter (Rotterdam, The Netherlands) investigators. Notably, such assumptions may be erroneous and, in fact, lead to faulty decisions concerning the potential of percutaneous revascularization to open the occluded vessel. Consequently, the histological relationship between the underlying plaque burden and thrombus content is unknown, yet this grade supposedly represents the highest thrombus load. With its hallmark characteristic of TIMI 0 flow, the ischemic vessel containing grade 5 thrombus is totally occluded. While this classification is user friendly and universally accepted, the accuracy of the highest level, grade 5, is subject to interpretation challenges.
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