Author + information
- Ching Ju Wu1
Patient initials or identifier number
Relevant clinical history and physical exam
Mr. Wang is a 62-year-old man with hypertension and CAD s/p stent at RCA-P and LAD-P at 2004. He was found to have micro-invasive SCC over left posterior tongue border and was admitted to ENT for scheduled operation. Operation with oral tumor wide excision was performed smoothly on Aug. 12th, 2016. However, he developed desaturation and shock at POR after extubation. Emergent re-intubation was done. A chest film showed acute pulmonary edema. ECG revealed STE at aVR and STD at I, II, aVF, and V4-6.
Relevant test results prior to catheterization
The Pre-operative general survey disclosed hemogram, coagulation file, renal and liver function tests within normal limits. Chest film revealed no cardiomegaly. ECG showed sinus rhythm with TWI at V5-6.
Relevant catheterization findings
CAG via right femoral artery showed total occlusion of the left main coronary artery, LAD-Os, LCX-Os and intermediate, suspect thrombus formation. RCA-M to-D in-stent was patient with collateral connecting RCA-D to LAD-M.
Due to cardiogenic shock, IABP was placed before the procedure. We engaged an XB 3.5/7 guiding catheter to left main coronary artery (LMCA). LCX and LAD were wired with Fielder FC guidewires. A Trek 2.0 mm balloon was inflated at LM to proximal LCX (pLCX) and a mini-trek 1.2 mm balloon was inflated at LM to proximal LAD (pLAD). However, subintimal dissection at pLAD was noted. So we rewired guidewire to dLAD and used a Trek 2.0 mm balloon for pLAD dissection. Next, we dilated the pLCX with an NC Quantum 2.5 mm balloon. Then extensive dissection of pLCX to distal LCX (dLCX) was found.n A Multi-link 2.5 mm BMS was deployed at pLCX to dLCX. After restoring LCX flow, IVUS showed a Medina 1, 1, 1 lesion of LM bifurcation and diffuse narrowing of LAD. Thus, we deployed a Multi-link 2.5 mm BMS at pLAD to middle LAD (mLAD). Then we performed Culotte technique with a Multi-link 2.75 mm BMS implanted at LM to pLCX and a Xience Xpedition 3.0 mm DES at LM to pLAD. Kissing balloon technique and proximal optimization technique were performed finally. However, the diagonal branch was jailed by the stent. A Sion guidewire was wired to the diagonal branch successfully and the flow was restored. But thrombus formation at LM bifurcation was noted and Export AP aspiration catheter was used. In addition, intracoronary Tirofiban was administered. Narrowing dLAD was found despite.
This is a case of peri-operative ST elevation myocardial infarction with LM total occlusion. Due to vulnerable coronary vessels, extensive dissection of LAD and LCX after balloon dilatation was observed. Thrombus formation and plaque shifting after coronary stenting multiplied the difficulties of percutaneous coronary intervention. The administration of intracoronary glycoprotein IIb/IIIa inhibitors was an alternative method to achieve better TIMI flow grade.