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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