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Patient initials or identifier number
Relevant clinical history and physical exam
A 50 year old very active gentleman with no coronary risk factors presented with Non ST Elevation Myocardial Infarction.
His TIMI risk score was 2/7.
He had no previous cardiac history.
He was non diabetic, non hypertensive and non smoker.
Physical examination unremarkable with normal cardiac and chest auscultation.
Chest pain resolved with nitrates and low molecular weight heparin.
He loaded on dual antiplatelets and underwent coronary angiogram the very next day.
Relevant test results prior to catheterization
Electrocardiogram showed dynamic ST-T changes in lateral leads.
Serial Troponin I showed rising trend from 70 to >1400 mIU/L.
His complete blood picture was normal.
Chest X Ray showed no evidence of cardiomegaly or fluid overload.
Echocardiogram showed no regional wall motion abnormalities with good left ventricular systolic function.
Normal renal parameters.
Relevant catheterization findings
Coronary angiogram was done through right radial artery access.
Left main coronary normal.
Left circumflex (LCx) dominant sytem with proximal 90% stenosis. First Obtuse marginal branch had ostial 40% disease.
RCA non dominat small vessel with proximal total occlusion.
Decision to intervene percutaneously was made.
Fractional flow reserve to mid LAD positive at 0.76.
Successful angioplasty to LAD done with 3.5 x 24 mm drug eluting stent.
Predilation of proximal circumflex (LCx) lesion with 3.0 mm balloon led to downstream spiral dissection in main LCx and 1st obtuse marginal branch leading to acute vessel closure.
Patient had severe chest pain with ST elevation.
Main circumflex stented with 3 drug-eluting stents in an overlapping fashion starting distally up to proximal LCx.
TIMI3 flow was restored in LCx but 1st OM had no flow due to ostial dissection. OM recrossed using hydrophilic tapered wire and TIMI 3 flow restored after ballooning.
Decided to do reverse crush bifurcation stenting but could not manage to pass stent into OM even after multiple attempts. Due to poor guide support through radial approach, we changed to femoral access. Next angiogram showed embolized un deployed stent in left main shaft which probably slipped off balloon while entering into OM through radial route.
Next injection pushed stent into circumflex artery near proximal stent.
Multiple attempts to snare the stent were made.
Distal end of the stent was caught in the under deployed struts of proximal circumflex stent. On pulling the stent with snare, it unraveled on itself forming a long thin thread extending from LCx into left main.After, failure to snare, we pushed stent thread with 2.0 mm balloon into circumflex completely.
LCx recrossed with wire and stent crushed into vessel wall with 3.0 mm balloon. Multiple attempts to pass IVUS failed.
So LCx ostium stented with 4.0 mm DES plastering embolized stent into vessel wall. Excellent final result.
Patient made excellent recovery.
On follow up after 1 month, patient was asymptomatic with complete restoration of his lifestyle
He advised to have long term dual antiplatelet therapy.
Hardware should never be pushed against resistance. In this case it led to stent slipping off the balloon.
Every lab should be equipped with various types of snares which prove handy in times of emergency.
Interventionists should always be ready with alternate plan.
Patience and presence of mind are the hallmark of good interventionist.