Author + information
Patient initials or identifier number
Mr. ME, 41 years old
Relevant clinical history and physical exam
Mr. ME, a 41-year-old male came to the emergency room complaining of typical chest pain since 11 hours ago. No shortness of breath, no palpitation, no history of hypertension, dyslipidemia and stroke, no previous heart attack history. He had been smoking 1 pack/day for 30 years. General condition was weak, but with stable vital signs: Blood pressure 110/80 mmHg, heart rate 90 bpm, respiratory rate 20 tpm, and no abnormal findings in heart and lungs auscultation and other physical examinations.
Relevant test results prior to catheterization
Chest X-ray was normal. Electrocardiogram showed 90 BPM sinus rhythm and anterior STEMI. CKMB level was 316.3 u/l, troponin I 5.13 ng/dl.
Relevant catheterization findings
Coronary angiogram showed single vessel disease with total occlusion at mid LAD.
Trans-radial puncture was done and “radial cocktail” consisting of 3000 unit of heparin and 0.2 mg isosorbide dinitrate was given intra-sheath to prevent spasm. Coronary angiography performed using 6F radial dedicated Tiger catheter. The result showed single vessel disease with total occlusion at mid LAD and high thrombus burden. The procedure then proceeded with EBU 3.0 6F guiding catheter, engaged at LMCA ostium and guide wire Asahi sion blue to distal LAD. A drop of blood pressure happened after engagement of catheter. Therefore, 50 ng Norepinephrine given through continuous intravenous pump. Due to high thrombus burden, GPIIB/IIIA inhibitor (eptifibatide) 180mcg/kg IV bolus was given, followed with bail out aspiration thrombectomy, but no thrombus was collected. Balloon angioplasty then performed using 2.0 x 15 mm balloon, dilated to 12 atm at mid LAD. After balloon deflated, suddenly there was no flow at the LAD. 0.3 mg nitrate was given intracatheter, but there was still no flow. Second thrombus aspiration was performed, and this time red thrombus was collected, and the flow was back (TIMI flow 2). The sirolimus-eluting stent then deployed at mid LAD, with post-dilation to 10 atm. The procedure was finished with a good angiographic result of TIMI flow 3 and door to balloon time: 90 minutes.
Trans-radial access is starting to become the access of choice in cardiac intervention, including in the setting of Primary PCI due to lower MACE, major bleeding, and mortality rate, and better patient comfort. Some arguments against trans-radial primary PCI were that the manipulation technique was more difficult and devices limitations for complicated cases, causing longer procedural time. This case reported a successful trans-radial primary PCI with a no-flow complication. It is successfully overcomed with no significantly different door to balloon time than the usual trans-femoral procedure.