Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
- 56-year-old gentleman
- Chronic smoker
- Good past healt
- Presented with sudden onset chest pain since 6:30 am on day of admission
- Arrived at emergency department at 8:30 am and transferred to catheterization laboratory for primary PCI by 9:00 am
Relevant test results prior to catheterization
- ECG: ST elevation over inferior leads
- CXR: clear
- Plasma troponin I: 0.414 ng/mL (normal<0.03 ng/mL)
Relevant catheterization findings
LAD: Aneurysmal change from p-mLAD, mLAD bifurcation lesion with significant mismatch
LCx: PLCx critical lesion 99% stenosis with TIMI II flow; very large thrombus (∼25 mm x 5 mm) and aneurysmal change after the tight lesion, hanging just distal to the stenotic lesion in pLCx. The size of mLCx was expected ∼7 mm. dLCx was blocked due to thrombus (TIMI 0 Flow)
RCA: Aneurysmal change in pRCA but overall RCA had minor lesions only
Aspirin, Ticagrelor, and IV Heparin is given prior to the procedure
IV bolus of Eptifibatide administered after coronary angiogram
XB 3.5 7F guiding engaged LM
The lesion was wired with BMW Uni II
After wiring, a patient developed cardiogenic shock. Lowest SBP down to ∼70 mmHg
Inotrope and IVF were given. The lesion was quickly predilated with Ikazuchi 1.5 x 15 balloon under low pressure. The flow was established and vital signs became stable. Crusade catheter was used for intracoronary injection of adenosine and TNK.
Thrombus load was reduced but still heavy. Flow to dLCx was re-established
Chest pain decreased to 1-2/10. No more compression feeling
ECG no more ST elevation
Patient likely will not tolerate stenting at this moment. No stenting was done in this procedure.
Staged Procedure (3 days later):
Restudy coronary angiogram found a significant reduction of thrombus in LCx dLCx flow was established.
The lesion was predilated with Ikazuchi 2.5 x 15 in low pressure. Adenosine and TNG were injected.
Pre-IVUS to LCx showed
- mLCx 6 mm in size in the proximal part of the aneurysmal change of the mLCx, p-ostial LCx 4-4.5 mm
- Proximal and distal landing site were identified
The lesion was further predilated with Lacrose NSE 3.0 x 13 up to 10 ATM
The lesion was stented with Stentys DES (p) 3.5-4.5/22
PSHP by Quantum Apex 4.0 x 15 for 3 times
1. Good landing without a geographical miss
2. Good opposition of all stent strut
3. No thrombus inside the stent
1) For patients who presented early after symptom onset (i.e.<3 hours), clots usually responded well to intracoronary thrombolytics. Such approach is supported by small trials using low dose intracoronary thrombolytics in primary PCI.
2) Consider defer-stenting in selected patients especially when there is significant thrombus load and further manipulation would likely cause the no-reflow phenomenon.
3) STENTYS self-expanding stent may be used even in acute setting if there is a significant mismatch in vessel size.