Table 1: Main differences in pathophysiology, diagnosis, and prevention of spontaneous and procedural distal embolisation.

Distal embolisation
Spontaneous Procedural
Stable CADACS

Clinical settingACS

Embolisate dimensionMacro- and microembolisation Macro- and microembolisation

Embolisate compositionAtherothrombotic fragments
Platelets aggregates
Platelet-monocytes aggregates
Microthrombi
Microparticles
Cholesterol crystal
Amorphous material
Humoral factors
Atherosclerotic fragments
Hyaline material
Fibrous material
Cholesterol crystal
As in spontaneous
DE

Biochemical activity↑↑↑↑↑↑

DiagnosisTrue diagnosis only at postmortem analysisLaboratory
 ↑ Troponin ↑ CK MB
Imaging
 MCE
 CMR
Cath-Lab
 TIMI flow
Laboratory
 ↑ Troponin ↑ CK MB
Imaging
 MCE
 CMR
Cath-Lab
 Intracoronary ECG
 ST resolution
 TIMI flow and cTFC
 MBG

Therapy and preventionPharmacologic
 Aspirin
 Clopidogrel
 Prasugrel/ticagrelor
 GPIIb/IIIa inhibitors
 Statin
 Vasodilators  (adenosine/nitroprusside)
Pharmacologic
 Aspirin
 Clopidogrel
 Statin
 GPIIb/IIIa* 
 Vasodilators*
Pharmacologic
 As in spontaneous
 DE
Mechanical
  none
Mechanical (only in SVG)
 Distal protection
  Balloon-based 
  Filter-based 
 Proximal protection
Mechanical
 thrombectomy

Only in complicated PCI.
ACS: acute coronary syndrome; CAD: coronary artery disease; CMR: cardiac magnetic resonance; cTFC: corrected TIMI frame count; DE: distal embolisation; MCE: myocardial contrast echocardiography; MBG: myocardial blush grade; TF: tissue factor; TIMI: thrombolysis in myocardial infarction.