Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
A 69 years old man had coronary risk factors of hypertension, diabetes mellitus, and old cerebral infarction and was treated for prostate carcinoma. He suddenly fell down at home and his wife witnessed him. She called EMS and an ambulance got there after 15 minutes. Emergency services checked that he was a cardiopulmonary arrest, after that CPR with LUCAS device and endotracheal tube intubation was done immediately and he was directly transferred to cath lab of out hospital.
Relevant test results prior to catheterization
The initial electrocardiogram (ECG) revealed VF in the cath lab.
CPK 64 IU/L and troponin T test was negative.
Relevant catheterization findings
Distal LM 99%, ostial LAD 90%, ostial LCX 99% (Medina 1,1,1), hypoplastic RCA
We implemented ultrasound-guided cannulation to left femoral artery and vein. It took only 12 minutes to induct V-A ECMO after the patient was transferred to cath lab first. Emergency coronary angiography showed that distal LM was 99% stenosis, after that, we performed emergency PCI. 6F Profit SS35 was engaged to LCA. It was easy to pass to distal LAD with SION. We tried to pass through distal LCX with SION blue, but it was not advanced to distal LCX because ostial LCX was calcified heavily. It was successful to pass through LCX using XT-R and Corsair. TIMI II flow in both LAD and LCX was restored and ECG revealed to convert to sinus rhythm from VF. Thrombus was not noticed although thrombus aspiration was performed. Kissing balloons Raiden 3.0×10 mm and IKAZUCHI ZERO 3.0×10 mm was inflated in LAD and LCX at 6 atm after checking IVUS. TIMI III flow was restored successfully, so BMX-J 3.0 × 14 mm was deployed from LM to LCX at 12 atm. After guidewire recrossing, the second BMX-J 3.0×14 mm was passed through stent struts of LM and deployed from the prior proximal stent edge to LAD at 12 atm (Y-stent technique). After guidewire recrossing, kissing balloons Raiden 3.0×10 mm and IKAZUCHI ZERO 3.0 × 10 mm was inflated in LAD and LCX at 8 atm. Final coronary angiography showed TIMI III flow in both arteries and no residual stenosis.
In a patient with acute occlusion of LMCA, it’s very common to develop serious complications like acute heart failure, cardiac shock, and cardiac arrest. It is very important to implement rapid primary PCI and induct life-supporting devices (ventilator, IABP, ECMO) in those cases. We perform cannulation using ultrasound when inducting ECMO, so we can induct it quickly and decrease bleeding complication. Therefore, this procedure can make good prognosis in ACS with LMCA occlusion.