Search Results (446)

Background and Clincal significance: Esophageal squamous cell carcinoma (ESCC) classically presents with progressive dysphagia and weight loss, but atypical presentations may redirect the diagnostic workup before the esophageal primary is identified. We report a case illustrating the simultaneous convergence of three diagnostic pitfalls: absence of dysphagia, bone-predominant metastatic presentation initially managed as carcinoma of unknown primary (CUP), and negative p40 staining in a vertebral biopsy in a patient subsequently confirmed to have invasive mid-esophageal squamous cell carcinoma. CasePresentation: A 66-year-old African American man with dementia, active tobacco exposure, and prior alcohol use disorder presented with constipation, abdominal pain, melena, fever, nausea, vomiting, and progressive back pain. Dysphagia or odynophagia was not documented. CT of the abdomen and pelvis demonstrated diffuse lytic osseous metastases. During evaluation and palliation of symptomatic L2 disease, kyphoplasty and radiofrequency ablation were performed, and bilateral core biopsies showed poorly differentiated carcinoma that was AE1/AE3-positive but negative for p40, CK7, CK20, TTF-1, S100, GATA-3, PAX8, and NKX3.1, yielding an initial diagnosis of CUP. Subsequent chest CT revealed esophageal wall thickening with intraluminal debris. Esophagogastroduodenoscopy (EGD) identified a non-obstructive ulcerated mid-esophageal lesion, and biopsy confirmed invasive squamous cell carcinoma. Poor performance status precluded systemic therapy; palliative external-beam radiation was initiated after diagnosis but discontinued because of clinical deterioration, and the patient transitioned to hospice before passing several weeks after diagnosis. Melena is a gastrointestinal alarm feature, and the combination of gastrointestinal bleeding and an esophageal imaging abnormality warrants timely endoscopic evaluation even when dysphagia is not reported or the symptom history is unreliable. Negative p40 staining in a poorly differentiated, potentially decalcified bone specimen may reflect loss of lineage-marker expression, technical antigen degradation, or both. Tissue or plasma genomic profiling and emerging cell-free DNA methylation classifiers could complement the workup but would not replace direct biopsy of a radiographically suspicious esophageal lesion. Conclusions: In metastatic poorly differentiated carcinoma, lack of documented dysphagia should not exclude an esophageal primary, particularly in patients with cognitive impairment. A p40-negative bone biopsy does not rule out squamous lineage. Timely EGD and integrated clinicopathologic assessment are essential when clinical or imaging findings suggest esophageal involvement. Full article

Background/Objectives: Primary thyroid lymphoma accounts for approximately 0.2–2% of thyroid malignancies. Plasmablastic lymphoma (PBL), an aggressive large B-cell neoplasm with plasma-cell differentiation and frequent loss of conventional B-cell markers, is a rare thyroid presentation. We report a thyroid PBL presenting as an acute surgical airway emergency in an immunocompetent patient and highlight the diagnostic and management pitfalls that distinguish this from anaplastic thyroid carcinoma. Case Presentation: A 75-year-old man without any significant past medical history presented with rapidly progressive right-sided neck swelling, dysphagia, inspiratory stridor, and respiratory failure. Imaging demonstrated a large, thyroid-centered mass with tracheal involvement, initially raising concern for anaplastic thyroid carcinoma. Histopathology revealed a diffuse infiltrate of large, atypical cells with immunoblastic and plasmablastic morphology. The neoplastic cells were CD20- and CD138-negative but strongly MUM1-positive, with lambda light-chain restriction, bright CD38 by flow cytometry, a Ki-67 proliferation index exceeding 95%, aberrant cytoplasmic CD3 expression, and a MYC::IGH rearrangement, supporting a diagnosis of PBL. Staging identified extranodal perinephric disease and mesenteric lymphadenopathy, consistent with disseminated extranodal Ann Arbor stage IV disease. The patient underwent systemic treatment and initially had an excellent response; however, one month after the last treatment cycle they presented to the hospital with a mass consistent with recurrence. Discussion: Rapid growth, fixation, and tracheal invasion strongly suggest anaplastic thyroid carcinoma in routine clinical practice. However, plasmablastic lymphomas can present similarly and require fundamentally different treatment. In this case, loss of conventional B-cell markers, CD138 negativity, and aberrant cytoplasmic CD3 expression created substantial diagnostic challenges. Light-chain restriction, plasma-cell-associated markers, flow cytometry, and MYC cytogenetics were vitally important. Conclusions: Thyroid-presenting PBL is exceptionally rare and may closely mimic anaplastic thyroid carcinoma, including presentation with life-threatening airway compromise and tracheal involvement. This case highlights several diagnostic pitfalls: CD138 negativity despite plasma-cell differentiation, and aberrant cytoplasmic CD3 expression. Prompt airway stabilization, adequate tissue acquisition, broad immunophenotyping, light-chain assessment, flow cytometry, EBV/HHV8/ALK testing, and MYC cytogenetics are essential for accurate diagnosis and lymphoma-directed treatment. Full article

Diffusion-weighted imaging (DWI) has evolved from a niche research sequence into an increasingly valuable adjunct to conventional magnetic resonance imaging (MRI) in musculoskeletal (MSK) radiology. By providing qualitative and quantitative information on tissue microstructure through assessment of water diffusion and apparent diffusion coefficient (ADC) mapping, DWI offers functional insights beyond conventional morphological imaging. We aim to present the current evidence for DWI in MSK imaging organised around established applications and emerging applications, with particular emphasis on composition-related interpretive pitfalls relevant to differentiating tumours and other pathologies, and to review the technique’s evolving role in routine practice. This narrative review synthesises the current literature on the clinical utility of DWI in MSK imaging. It is structured in four parts: foundations and the tissue composition signal framework, including the basis of qualitative and quantitative assessment; established applications; emerging applications; and assessment of tissue composition-related interpretive as well as technical pitfalls, including those arising due to myxoid matrix, chondroid matrix, blood degradation products, organising thrombus, crystalline or mineralised material, keratinaceous debris, purulent content, cellular haematopoietic marrow, by using original cases from the authors’ institution, which have been confirmed either histologically or surgically. Applications are stratified by strength of evidence. Established applications of DWI include soft tissue abscess detection, differentiation of malignant from benign soft tissue tumours, differentiation of malignant from benign vertebral compression fractures, and myeloma staging and response assessment, as well as treatment response in soft tissue and bone sarcomas. Whole-body MRI with DWI for staging and response assessment in multiple myeloma is guideline-endorsed and supported by prospective multicentre data. Soft tissue abscess detection, soft tissue and bone tumour characterisation, and characterisation of vertebral compression fractures are supported by consistent evidence from multiple independent cohorts, although no universally transferable ADC threshold exists. The emerging applications, which are promising adjuncts supported by small, single-centre or heterogeneous studies with thresholds that have not been externally validated, include ADC ghost sign in osteomyelitis (high specificity but sensitivity of only 20%), peripheral nerve sheath tumour characterisation and surveillance in NF1 patients, peripheral neuropathy and plexopathy, predisposing conditions such as Li Fraumeni syndrome in paediatric cancers, inflammatory myopathy, and postsurgical assessment of residual disease, as well as opportunistic detection of venous thrombosis. Radiomics and machine learning approaches remain experimental. Recent technical advances, including reduced field-of-view imaging, multi-shot acquisition and improved fat suppression, have mitigated but not eliminated historical limitations of susceptibility artefacts and limited spatial resolution. DWI has become an important functional imaging technique that complements conventional MRI across a broad range of musculoskeletal disorders. Understanding the relationship between tissue composition and the diffusion signal is central to both interpreting DWI correctly and avoiding its characteristic pitfalls. DWI is best regarded not as a stand-alone technique but as one component of a multiparametric assessment, in which its functional information is integrated with conventional morphological imaging. Ongoing technical improvement and expanding clinical evidence are expected to further support its integration into routine MSK imaging and its development as a quantitative biomarker for diagnosis, prognostication, and treatment monitoring. Full article

The recent introduction of “molecularly defined renal cell carcinomas” in the World Health Organization classification has significantly expanded the diagnostic spectrum of renal neoplasia, highlighting entities characterized by specific genetic alterations with potential clinical and therapeutic relevance. However, the recognition of these tumors in routine practice remains challenging due to overlapping morphological features and variable access to molecular testing. In this context, immunohistochemistry (IHC) has emerged as a practical and widely available tool that can act as a surrogate for underlying molecular alterations. Depending on the biological context, IHC may reflect genetic events either through protein overexpression, as in fusion-driven tumors, or through loss of expression associated with gene inactivation in metabolically or chromatin remodeling-deficient neoplasms. Accordingly, IHC plays a central role as a screening and triage method within the diagnostic workflow of these entities. Overall, IHC remains an indispensable component in the evaluation of molecularly defined renal cell carcinomas, but its optimal use requires integration with morphological assessment and, in most cases, confirmatory molecular testing. The aim of this review is to provide a comprehensive and evidence-based overview of the main immunohistochemical surrogates used in molecularly defined renal cell carcinomas, including TFE3-, TFEB-, and ALK-rearranged tumors, as well as SDH-, FH-, and SMARCB1-deficient neoplasms, highlighting their diagnostic applications, strengths, pitfalls, and role within an integrated diagnostic workflow. For each marker, the biological rationale, expected staining patterns, diagnostic applications, and major pitfalls are discussed, with particular emphasis on variability across studies and technical limitations. Full article

Human T-cell lymphotropic virus type 1 (HTLV-1) is a neglected pathogen with a heterogeneous global distribution. In low-prevalence areas, diagnostic testing is challenged by limited clinical awareness and the low positive predictive value of screening tests. We retrospectively analyzed 10,891 HTLV-1/2 test results from 7719 patient samples submitted to a specialized laboratory in Germany between 2004 and 2024. Antibody screening had a positive predictive value (PPV) of 31.7% for the Diasorin Murex HTLV I + II assay (39 of 123 reactive samples confirmed) and 34.5% for the Abbott Architect rHTLV-1/2 assay (67 of 194 reactive samples confirmed). Raising the sample/cutoff (s/co) threshold to ≥5 would have increased the PPV to >80%, with only two missed diagnoses per assay. HTLV-1 infection was confirmed in 124 carriers and HTLV-2 infection in three carriers. The vast majority of carriers originated from countries with higher endemicity. A delayed antibody response was observed in HTLV-1 infections via organ transplantation. In four patients with neurological disease, elevated HTLV-1/2-specific antibody indices showed antibody production in cerebrospinal fluid (CSF). HTLV-1 proviral load was measured in 83 carriers, with a median of 20,000 HTLV-1 DNA copies per 10⁶ cells (interquartile range, 4000–119,600). Seventy-four percent (17/23) of high-dose intravenous immunoglobulin (IVIg) preparations contained HTLV-1/2 antibodies, which can lead to false-positive HTLV-1/2 antibody screening results in recipients without underlying infection. Therefore, HTLV-1/2 testing presents two major pitfalls: false-negative results in immunosuppressed patients and false-positive results following IVIg administration. Full article

Chikungunya poses a major clinical and public health challenge due to its wide range of manifestations and, consequently, frequent misdiagnoses. This pitfall may lead to compromised long-term outcomes when treatment is inadequate. This scoping review aims to summarize the clinical features, current management strategies, and long-term outcomes of chikungunya infection in adults. The review was designed and reported according to Joanna Briggs Institute (JBI) guidance and the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) framework. Three main databases—PubMed, ScienceDirect, and Wiley Online Library—were searched, and additional gray literature from international and national health agencies was consulted. Nineteen studies met inclusion criteria. Chikungunya in adults commonly begins as an acute febrile illness with prominent musculoskeletal symptoms, but may evolve into a chronic, disabling disease, substantially impairing quality of life. Treatment is largely symptomatic for the acute phase, whereas chronic infections require long-term multidisciplinary care, supported by preventive measures through public health interventions. In summary, while most patients recover with appropriate care, a significant number of patients experience persistent sequelae requiring rehabilitation, continued clinical follow-up, and targeted preventive and public health actions. Full article

Background and Clinical Significance: Peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) substantially alters aortic flow dynamics, generating catastrophic false-positive pathology on standard imaging. We report a case of ECMO-induced artifacts mimicking a Stanford type A aortic dissection (TAAD), which led to an unnecessary exploratory sternotomy. Case Presentation: A 67-year-old man underwent extracorporeal cardiopulmonary resuscitation (ECPR) for a shockable out-of-hospital cardiac arrest. Post-resuscitation chest computed tomography angiography (CTA) and preoperative transesophageal echocardiography (TEE) demonstrated a prominent flap-like structure in the ascending aorta, prompting emergency sternotomy. Intraoperative exploration revealed no intimal tear. Subsequent evaluation confirmed an acute anterior myocardial infarction, managed with coronary intervention. Following a dismal neurological prognosis due to hypoxic encephalopathy, VA-ECMO was palliatively withdrawn on day 9, and the patient expired on day 19. The interaction between retrograde ECMO flow and varying levels of intrinsic cardiac function dictates the topology of flow disturbances. Absent native flow creates contrast layering within the aortic root, whereas preserved native flow creates a volatile downstream watershed zone. Based on these distinct phenotypes, we propose a novel conceptual framework for tailor-made imaging strategies titrated to native flow strength—such as temporary ECMO flow reduction for preserved native output, or circuit contrast injections for profound cardiac depression. Conclusions: ECMO-related artifacts present substantial diagnostic pitfalls. Clinicians should adopt a context-aware approach, integrating multi-modality imaging with hemodynamic status to implement individualized, physiologically guided imaging protocols. Full article

The integration of immunohistochemical biomarkers like PRAME (Preferentially Expressed Antigen in Melanoma) into the histomorphological assessment of melanocytic lesions is gaining prominence. While PRAME’s diagnostic value is widely recognized, its independent weight compared directly to classical morphology remains underexplored in large, challenging cohorts. This retrospective study quantifies the diagnostic utility of PRAME alongside traditional histomorphology in a high-risk cohort of 954 primary melanocytic lesions (335 nevi, 215 melanomas in situ, 404 invasive melanomas) where PRAME was clinically requested to resolve diagnostic ambiguity. Using Firth’s penalized likelihood regression, a baseline diagnostic model utilizing 13 histomorphological features was established and subsequently integrated with PRAME expression. The pure morphology baseline model demonstrated a high cross-validated area under the curve (AUC) of 0.969. As a standalone marker, PRAME achieved an AUC of 0.895, with a diffuse expression score of 4+ yielding peak specificity (94.3%) and moderate sensitivity (77.9%). Integrating PRAME into the morphological model significantly enhanced diagnostic accuracy (AUC: 0.980; p < 0.001), establishing PRAME as a dominant independent predictor of malignancy alongside core features like junctional atypia and upward melanocytes (Odds Ratio 19.08 for Score 4+). Analysis of discordant cases revealed that completely PRAME-negative melanomas were morphologically indistinguishable from typical PRAME-positive melanomas. Conversely, diffusely PRAME-positive (4+) nevi exhibited significantly higher rates of upward migrating melanocytes, constituting a critical diagnostic pitfall. In conclusion, while classic histomorphology remains the indispensable gold standard in dermatopathology, PRAME functions as a highly objective, reproducible tie-breaker. The synergistic integration of PRAME with morphological assessment effectively resolves diagnostic ambiguity and maximizes diagnostic confidence in challenging melanocytic lesions. Full article

The renal resistive index (RRI) is a Doppler-derived parameter influenced by intrarenal hemodynamics, vascular compliance, pulsatile load, and systemic cardiovascular factors. In outpatient nephrology practice, RRI may provide adjunctive hemodynamic and prognostic information when interpreted together with kidney morphology, estimated glomerular filtration rate, proteinuria, blood pressure, heart rate, rhythm, and cardiovascular context. This protocol aims to standardize duplex Doppler acquisition, calculation, interpretation, and reporting of RRI in outpatient adults with native-kidney chronic kidney disease (CKD). The protocol defines patient eligibility and preparation, same-visit clinical data collection, grayscale kidney assessment, color Doppler localization of intrarenal arteries, pulsed-wave Doppler settings, bilateral upper-, middle-, and lower-pole sampling, waveform validity criteria, RRI calculation rules, image archiving, and structured reporting. Technical pitfalls and hemodynamic confounders are incorporated into the workflow to support reproducibility and serial comparability. The expected output is a standardized RRI report including kidney-specific and bilateral mean RRI values when minimum validity criteria are met, the number and location of valid sampling sites, grayscale morphologic findings, same-visit hemodynamic context, relevant technical limitations, and interpretive caveats. The protocol is designed to reduce acquisition variability and improve the consistency of RRI documentation in outpatient CKD practice. RRI should not be interpreted as a stand-alone diagnostic test or direct surrogate of renal vascular resistance. A standardized acquisition and reporting protocol may improve reproducibility and allow RRI to be used more appropriately as an adjunctive hemodynamic and prognostic marker in adults with non-dialysis-dependent CKD. Full article

The carotid and vertebral arteries are critical components of the cerebral circulation, supplying the brain and spinal cord. Their embryologic development involves complex transformations of the aortic arches, paired dorsal aortae, and cervical intersegmental arteries. Congenital anomalies and variations involving their origin, course, and branching patterns are relatively common and are increasingly recognized using modern imaging. While many of these variants are incidental, some carry important clinical implications, particularly in contexts of stroke imaging, head and neck surgery, and neurointerventional procedures. This article reviews the embryologic development of the carotid and vertebral arterial systems, highlights normal and variant anatomy, and presents a case-based, illustrated overview of these congenital anomalies. Emphasis is placed on key findings utilizing computed tomography angiography (CTA), magnetic resonance angiography (MRA), and catheter angiography. Particular attention is given to structural and pathway variations, including vessel agenesis or hypoplasia, the aberrant internal carotid artery within the temporal bone, abnormal branching patterns, fenestrations, and persistent fetal anastomoses (such as the primitive trigeminal, hypoglossal, and proatlantal intersegmental arteries). Ultimately, familiarity with these anomalies, their embryological origins, and their distinct imaging characteristics is essential for ensuring accurate interpretation and avoiding diagnostic pitfalls and procedural complications. Full article

Spontaneous coronary artery dissection (SCAD) and Takotsubo syndrome (TTS) are two conditions presenting as acute coronary syndromes that predominantly affect women and are frequently triggered by emotional or physical stress. While traditionally considered distinct entities, emerging evidence suggests that these conditions may coexist more frequently than previously recognized, sharing common pathophysiological mechanisms centered on catecholamine-mediated pathways, vascular vulnerability, and hormonal influences. Their overlapping presentations create significant diagnostic challenges that may lead to misdiagnosis and suboptimal management. This narrative review examines the pathophysiological convergence between SCAD and TTS, addresses the diagnostic complexity arising when these entities coexist, and proposes a novel stepwise diagnostic algorithm integrating clinical risk stratification, coronary angiography, intracoronary imaging, and cardiac magnetic resonance imaging. The review also provides scenario-dependent management guidance and outlines priorities for future research. Full article

To provide a clinically oriented overview of ultrasound elastography in chronic liver disease, focusing on currently available techniques, their clinical applications, quality assurance, technical pitfalls, and emerging developments that may shape future liver imaging practice. A narrative review of the current literature was conducted using international guidelines, systematic reviews, and original studies retrieved from major scientific databases. Particular emphasis was placed on the clinical applications of ultrasound elastography, quality assurance procedures, interpretation of liver stiffness measurements, and future technological developments. Vibration-controlled transient elastography (VCTE) and shear wave elastography (SWE) have become established non-invasive techniques for liver fibrosis assessment, demonstrating excellent diagnostic performance, particularly for advanced fibrosis and cirrhosis. Beyond fibrosis staging, ultrasound elastography contributes to prognostic stratification, treatment planning, and longitudinal disease monitoring across a broad spectrum of chronic liver diseases. However, liver stiffness measurements may be influenced by technical and biological confounding factors, including inflammation, cholestasis, hepatic congestion, obesity, and postprandial status, highlighting the importance of standardised acquisition protocols and careful clinical interpretation. Emerging developments, including spleen stiffness assessment, multiparametric ultrasound, and artificial intelligence-assisted image analysis, are expected to further improve diagnostic accuracy and support precision hepatology. Ultrasound elastography has become an essential component of the non-invasive evaluation of chronic liver disease, substantially reducing the need for liver biopsy while improving fibrosis staging, prognostic stratification, and longitudinal patient monitoring. Its optimal clinical implementation requires appropriate patient selection, adherence to quality assurance procedures, and careful interpretation within the broader clinical context. Future advances in multiparametric ultrasound, artificial intelligence, and international standardisation are expected to further strengthen the role of ultrasound elastography within precision hepatology and personalised liver disease management. Ultrasound elastography should be integrated into routine liver imaging as part of a multimodal diagnostic approach. Standardised acquisition protocols, continuous quality assurance, and appropriate operator training are essential to ensure reliable and reproducible liver stiffness measurements. Radiographers play a key role in examination quality, protocol adherence, and multidisciplinary patient care, contributing to accurate diagnosis and improved clinical decision-making. Full article

Dural-based lymphomas are rare extranodal non-Hodgkin lymphomas that span from indolent primary dural entities, most commonly the extranodal marginal zone (mucosa-associated lymphoid tissue) lymphoma, to aggressive variants that are primary or represent secondary involvement from systemic lymphoma. They overlap radiologically with benign meningiomas, dural metastases, and immune-mediated pachymeningitis, creating a risk of anchoring bias, delayed diagnosis, and unnecessarily extensive resections when limited tissue sampling would be sufficient for diagnosis. We conducted a structured narrative review to synthesize the epidemiology, clinico-pathological classification, imaging phenotypes, and management principles of dural lymphomatous disease. This study will especially focus on primary dural lymphoma (PDL) with additional discussion of secondary dural involvement. Emphasis is placed on the clinical value of a multiparametric diagnostic approach that integrates computed tomography contrast-enhanced magnetic resonance imaging with functional techniques, and fluorodeoxyglucose positron emission tomography/computed tomography for systemic staging and for distinguishing truly localized primary dural lymphoma from secondary involvement. Potential diagnostic pitfalls related to somatostatin receptor–based tracer uptake will also be discussed. We introduced a pragmatic operational framework based on four clinico-biological clusters, translated into a step-by-step decision algorithm that prioritizes timely biopsy and comprehensive hematologic staging to guide surgical strategy. Given the absence of dedicated, multidisciplinary guidance for dural-based lymphomas, this algorithm is intended as a reproducible foundation for consensus recommendations and future multicenter validation. Full article

Mitral stenosis (MS) remains a clinically relevant condition worldwide, with rheumatic and degenerative aetiologies contributing to a broad spectrum of disease. Accurate assessment of MS severity is essential for clinical decision-making but is often challenged by technical limitations, complex hemodynamic interactions, and the heterogeneous anatomical characteristics of different MS aetiologies. This review aims to provide a comprehensive overview of the contemporary multimodality imaging assessment of MS, with particular emphasis on the pitfalls of conventional transthoracic echocardiography (TTE), the incremental value of advanced imaging modalities, and their integration into diagnostic and therapeutic decision-making. A targeted narrative review of the literature was conducted focusing on multimodality imaging approaches and their integration into clinical practice. Particular emphasis was placed on TTE parameters, three-dimensional (3D) TTE, stress echocardiography, transoesophageal echocardiography (TOE), cardiac computed tomography (cCT), and cardiac magnetic resonance (CMR), highlighting their complementary roles in anatomical characterization, hemodynamic assessment, procedural planning, and clinical decision-making. Conventional 2D TTE remains the cornerstone for MS evaluation; however, widely used parameters such as mean transmitral gradient (TMG) and pressure half-time (PHT) are highly load-dependent and may lead to misclassification of disease severity in the presence of altered hemodynamic conditions (e.g., tachycardia, atrial fibrillation (AF), or reduced cardiac output). Although direct planimetry remains the anatomical reference standard, its accuracy may be limited by operator dependency, calcification, and complex valve geometry. In this context, three-dimensional TTE (3D TTE) provides incremental value by enabling more accurate visualization of the mitral valve (MV) orifice and improving measurement reproducibility. Stress TTE plays a key role in patients with discordant symptoms or borderline resting findings by unmasking clinically significant disease during exercise. In selected patients, TOE, cCT, and CMR provide complementary information for the evaluation of complex valve morphology, mitral annular calcification (MAC), ventricular remodelling, and procedural planning, particularly in degenerative mitral stenosis (DMS) and candidates for transcatheter interventions. The evaluation of MS requires an integrated, multiparametric, multimodality imaging approach. Combining conventional TTE with stress imaging and complementary advanced modalities improves diagnostic accuracy, facilitates patient selection for intervention, and supports individualized clinical decision-making, particularly in patients with complex anatomy or discordant imaging findings. Full article

Large intracoronary thrombus burden during percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) remains technically challenging when conventional manual aspiration is ineffective or dedicated thrombectomy systems are unavailable, unsuitable, or undeliverable. Routine aspiration thrombectomy is not guideline-supported, but selective bail-out thrombus-removal strategies remain relevant in refractory thrombus-rich PCI. This contemporary narrative review, supplemented by six retrospective single-center clinical examples, describes off-label guide-extension catheter (GEC)-assisted thrombus aspiration and places it within the current thrombectomy landscape, including manual aspiration catheters, sustained mechanical aspiration platforms, and stent-retriever-based systems. The heterogeneous examples, predominantly involving the right coronary artery, are educational and hypothesis-generating only: they illustrate procedural mechanics, patient selection, technical pitfalls, and risk mitigation, but do not provide efficacy or safety evidence. GEC-assisted aspiration may be considered when bulky proximal thrombus cannot be captured by smaller catheters or when a GEC can be positioned coaxially near the thrombus face under uninterrupted negative pressure. The technique remains operator-dependent, off-label, and anatomically constrained and should be regarded as a contingency maneuver rather than an alternative to purpose-built systems with more formal device-specific evaluation. Prospective registries and comparative studies are required before efficacy, safety, or relative value can be established. Full article