Author + information
- Imran Ahmed1
Patient initials or identifier number
Relevant clinical history and physical exam
A 31 years old male was admitted with typical angina that began 9 hours back. He was a current smoker, non-diabetic and non-hypertensive. His blood pressure was 100/70 mmHg and heart rate 104 /min. No abnormal sounds or cardiac murmur was auscultated.
Relevant test results prior to catheterization
His ECG revealed an ST-elevation MI in anterior leads, including in aVR and V1. Echocardiogram showed moderate LV dysfunction (EF–35%) and a hypokinetic but viable LAD territory. Troponin T was elevated. Serum creatinine was 1.01 mg/dl and random blood sugar–164 mg/dl. The patient was loaded with oral aspirin 325 mg, ticagrelor 180 mg and atorvastatin 80 mg.
Relevant catheterization findings
A coronary angiogram (CAG) was performed. CAG established anterior wall MI with an ostio-proximal LAD occlusion and faint distal LAD filling retrogradely via collaterals. A PTCA to LAD was planned and the patient was given Inj unfractionated Heparin at 70u /Kg IV.
PTCA was done via femoral access with an EBU3 7F catheter. Run through, XTF wire was parked into LAD blindly. Multiple sequential balloons were inflated but LAD flow distal to a major proximal Diagonal could not be achieved. As the patient deteriorated, IC vasodilators (nicorandil 1 mg, diltiazem 1 mg and nitroprusside 500 mcg), IC abciximab and thrombosuction were attempted in vain. As a last resort, a “perfusion” balloon was designed by inserting needle punctures to a 2.5 x 10 mm semi-compliant balloon. The “perfusion” balloon was positioned in mid LAD beyond occlusion and inflated with a dye solution of nitroglycerin. The attempt succeeded in delivering the vasodilator distally in the LAD and flow could be established. Further predilation with a 3 x 10 mm semi-compliant balloon was done. The proximal LAD was stented with Promus Element Plus stent (3.0 x 28 mm) at 14 atm pressure and subsequently postdilated with a 3 x 12 mm non-compliant balloon. The patient achieved a final TIMI 3 flow and was discharged after 3 days of hospital stay.
Establishing flow in an occluded artery is the urgent requirement in a primary PCI situation. The present case highlights an effective, simple, low-cost innovative technique of creating a “perfusion” balloon in the cath lab and successfully delivering intracoronary vasodilator distal to a tight occlusion in the LAD vessel. The innovation helped in bailing-out the patient and allowed for completion of subsequent stenting and salvage of the patient after routine measures had failed. The author through this innovative technique highlights the challenges of a primary PCI procedure and the constant need to think out-of-the-box to save the occasionally complicated patient.