Case report
A
62-year-old man presented to his family doctor with a history of chest
pain at rest for the past four days. He was diagnosed with
non-ST-segment elevation myocardial infarction (NSTEMI) and was referred
to our institute. His blood pressure and heart rate were 134/67 mmHg and
81 beats/min, respectively. The physical examination revealed a high
body mass index (27.6 kg/m2) and normal heart sounds
without peripheral edema.
The patient had a 20 years history of smoking along with dyslipidemia
and hyperuricemia, managed with anti-dyslipidemic and anti-hyperuricemic
medications. Laboratory investigations revealed 0.853 ng/ml of troponin
T level and 892 pg/ml of NT-proBNP level. Electrocardiography showed a
regular sinus rhythm with abnormal Q waves and negative T waves in the
inferior leads, and ST-segment depression in leads V4–6. Also, mild
hypokinesis was observed in the inferior area with a left ventricular
ejection fraction of 59.6%. Coronary angiography (CAG) revealed total
thrombotic occlusion of the ostial right coronary artery (RCA) and no
organic stenosis in the left coronary artery (Figure 1). Urgent PCI was
performed. The patient was administered with aspirin (200 mg), prasugrel
(20 mg), and heparin (9,000 international units). An 8-French Judkins
Right catheter (Hyperion JR 3.5, ASAHI INTECC Co., Ltd., Seto, Japan)
was inserted from the femoral artery and engaged in the RCA, and a
0.014-inch guidewire (ULTIMATE bros 3, ASAHI INTECC Co., Ltd., Seto,
Japan) was passed into the thrombotic lesion with a
microcatheter. Although, balloon
dilatation (2.5 mm) was performed in the ostium of the RCA (Figure 2A),
reperfusion could not be achieved (Figure 2B). Subsequently, aspiration
thrombectomy was attempted several times using an aspiration catheter
(Rebirth Pro2; NIPRO Co, Osaka, Japan). However, the subsequent CAG
showed that a high thrombus burden remained in the RCA (Supplemental
file). After CAG, the patient suddenly developed a headache, dysarthria,
and paralysis of the right upper and lower limbs. We suspected acute
cerebral infarction, and the neuro-interventionalist immediately
performed cerebral angiography, which showed complete occlusion of the
right posterior cerebral artery (Figure 3A). Endovascular thrombectomy
was performed by a direct aspiration first pass technique using the AXS
Catalyst 6 catheter (Stryker Japan K.K., Tokyo, Japan). The tip of the
AXS Catalyst 6 catheter reached the occluded site, and the thrombus was
aspirated from the tip. The right posterior cerebral artery was
successfully re-perfused (Figure 3B). No further PCI procedures were
performed, and the final thrombolysis in myocardial infarction flow was
of grade 2. An intra-aortic balloon pump (IABP) was added to improve
coronary flow and was removed 3 days later. Follow-up coronary computed
tomography angiography revealed a residual thrombus in the RCA after 1
week (Figure 4). However, the patient continued with rehabilitation and
was discharged with slight right upper limb paralysis on day 19. He did
not complain of chest discomfort or dyspnea upon discharge.