Author + information
- Takahiro Kusume1
Patient initials or identifier number
Relevant clinical history and physical exam
The patient was 80-year-old female. She had hospitalized in a division of gastroenterology in our hospital because of ileus and gallstones.Although she had been taking a direct oral anticoagulant (DOAC) for paroxysmal atrial fibrillation (AF), DOAC discontinued because of endoscopic therapy for gallstones. Seven days after withdrawal, he was found lying on a bed with disturbed consciousness. She was in shock state with blood pressure 70/50 mmHg. Her heart rate was 70 bpm and rhythm was regular.
Relevant test results prior to catheterization
Her 12 leads electrocardiogram (ECG) showed AF with a rapid ventricular response at the rate of 139 bpm. We could see extensive ST depression in near all leads except ST elevation in aVR. The echocardiogram demonstrates diffuse left ventricular asynergy. The chest roentgenogram showed pulmonary congestion.
Relevant catheterization findings
Coronary angiogram showed totally occluded left main trunk (LMT). We could see no significant stenosis in right coronary artery and poorly developed collateral to left descending artery (LAD) via a septal branch.
First, at all, we initiated Intra-aortic balloon pumping (IABP) and respiratory assist using Biphasic Positive Airway Pressure (BiPAP). The guide catheter was 7Fr. Launcher SL 3.5 inserted via a right femoral artery. Guide wire Route and Run-through extra-floppy were progressed into LAD and left circumflex artery (LCX) respectively. At this point, the large filling defect could see in distal LMT, which thought to be a thrombus. We tried to aspirate this deficit using an aspiration catheter (Thrombuster III) but failed. After we dilated the 2.5 x 15 mm balloon (Kunai) toward LAD, LAD antegrade flow was restored. Nevertheless, the filling defect moved to LCX side and interrupted LCX flow. Therefore, we dilated simultaneously toward LAD and LCX using kissing balloon technique (Ikazuchi Zero 3.0 x 15 LAD, Kunai 2.5 x 15 mm @LCX). The filling defect in LMT completely disappeared and antegrade flow in both LAD and LCX restored. Unfortunately, we could find out another filling defect in mid LAD, which might have moved from LMT. Again, we tried to aspirate the defect, and this time succeeds to remove these defects. The aspirated specimens were a thrombus. Though intravascular ultrasound images showed no evidence of plaque rupture around the LMT, this event thought to be due to thromboembolization.
In the case with suspicious of thromboemboliztion, persistent aspiration might be useful, even after balloon dilatation. Distal movement of thrombus might be a good sign of successful removal of thrombus. In AF patients, strategy without stenting must be better, because which can avoid the risk with triple therapy (double anti-platelet + OAC).