Author + information
- Nazim Megherbi1,
- Mohamed Abed Bouraghda1,
- Redwane Nedjar1,
- Said Benghezel1,
- Wathik Takdemt1,
- Mohamed Chettibi1 and
- Mohamed Tahar Chafik Bouafia1
Patient initials or identifier number
patient 1: H.A / patient 2 : H.S
Relevant clinical history and physical exam
29 years old patient, smoker, consults for a typical chest pain evolving since 3 hours.
Clinical examination: KILLIP II, patient agitated
38 years old patient, smoker, with a history of NSTEMI on 02/05/2016 the angiography at that time showed a sténosis on the circumflex, we did put an Ativ stent on it with good results.
He consults on 17/10/2016 for typical chest pain evolving for 1-hour.
Clinical examination was normal.
Relevant test results prior to catheterization
Patient 1: EKG: acute anterior STEMI.
Patient 2: The EKG highlighted subendocardial lesions in the anterior territory.
Troponin T was elevated at 56 times the normal limit.
The echocardiogram was unremarkable. The ejection fraction was approximate.
Relevant catheterization findings
Patient 1: Large thrombus on the distal LM and ostial CX.TIMI 0 flow on the LAD. Patient 2: Very Severe heterogeneous stenosis of the left main, TIMI III flow on the LAD and the Cx.The right coronary was normal.The patient was stable without any pain, the blood pressure was about 140/70.
- We placed the patient under intra-aortic counterpulsation.
- We performed instrumental thrombectomy with perfusion of TIROFIBAN intra-coronary and intravenous.
- We restored a TIMI III flow with sedation of chest pain.
- The patient was observed for 48 hours in an intensive care unit under intravenous perfusion of TIROFIBAN for 24 hours.
- At angiographic control after the 48 hours, we noticed the disappearance of the thrombus, the left coronary artery was free from the angiographically significant lesion.
- We placed the patient in observation in intensive care unit during 48 hours, where he received a perfusion of TIROFIBAN for 24 hours.
- At the angiographic control after the 48 hours, the lesions were identical to those observed during the first angiography.
- We performed the angioplasty of the ostial left main.
- Predilatation of the lesion with a semi-compliant balloon and then with a compliant balloon. We did found resistance at the lesion's predilatation.
- Placement of an active stent covering the LM ostium with persistence of an imprint on the middle segment at the deployment of the stent.
- Post-dilation with a non-compliant balloon with the good angiographic result.
Stable TIMI3 flow is the aim of primary PCI which can be performed with thrombectomy combined to anti-GP IIb, IIIa without stenting for the first step to avoid distal embolization and stent downsizing in young patients who sometimes have not significative coronary lesions, this is true for many of them, but not all.
It is difficult to identify those likely to receive a deferred strategy.
Nevertheless, this strategy must be adopted only when we are sure to ensure the safety of our patients.