CASE REPORT
A 40-year-old male smoker and tobacco chewer presented to the emergency
department eight hours after onset of resting angina. The patient’s
history was unremarkable without any record of similar symptoms
experienced earlier. He also did not have a family history of ischemic
heart disease. His physical examination revealed a heart rate of 116
beats/min, blood pressure of 90/66 mmHg, respiratory rate of 20
breaths/min, and oxygen saturation (SPO2) of 88%.
Electrocardiography showed ST elevation in V2-V6, I, and aVL, suggestive
of anterior wall myocardial infarction (AWMI). During hospitalization,
the patient developed hemodynamically unstable ventricular tachycardia
(VT) which was treated with DC cardioversion. The patient was
immediately rushed to the cath-lab for primary PCI.
After engaging the LMCA with a 6F EBU 3.5 Launcher guiding catheter
(Medtronic Inc, Minneapolis, USA) an occlusion within the LMCA was
encountered. Initial considerations included the possibility of a
dissection induced by the guide catheter or a complete thrombotic
occlusion of the LMCA, given the absence of observable branches or
distal vasculature beyond this occlusion point (Fig 1. & Video
1) . Due to complaints of persistent chest pain by the patient, cautious
advancement of the workhorse guide wire was performed, leading to an
extension of staining. Finally, the lesion was crossed using a Fielder
FC guidewire (polymer jacket and hydrophilic wire, Asahi Intecc, Aichi,
Japan) originally intended for wiring the left anterior descending
artery (LAD) and achieving some flow (Fig. 2) , but ultimately
went into a diagonal branch (Video 2) . As the thrombosuction
catheter was unable to cross, the LMCA lesion was pre-dilated with a 2 x
10 mm semi-compliant balloon.
After establishment of partial blood flow within the LMCA (Fig.
2) , a 6 x10 mm aneurysm was discovered in the LMCA (Fig. 3 &
Video 3) . The case was discussed with among the cardiothoracic surgical
team. The decision was made to pursue revascularization using PCI. Two
other Fielder FC wires were introduced into both the LAD and the ramus
intermedius (RI). Dilation of the RI was also performed with a 2 x 10 mm
semi-compliant balloon( Fig. 4 & Video
4) While both LAD and RI achieved thrombolysis in myocardial infarction
(TIMI) grade I flow, efforts to wire the left circumflex artery (LCx)
were unsuccessful (Video 5) . Consequently, a decision was made
to employ a 5F TIG diagnostic catheter (Terumo Corporation, Shibuya -Ku,
Tokyo) to perform an angiogram of the right coronary artery (RCA)s via
the radial route. This imaging revealed the RCA was normal, however, a
grade 3 retrograde collateral circulation was evident from the RCA to
the LCx, suggestive of LCx chronic total occlusion (CTO) (Fig. 5
& Video 6) .
Our intended approach involved the placement of a covered stent in the
LM-LAD. However, due to the delayed availability of the designated stent
and the patient’s compromised hemodynamic state, a 3.5 x 20 mm Promus
Elite stent (Everolimus Eluting Platinum Chromium Coronary Stent System,
Boston Scientific Corporation, Marlborough, USA) was deployed from LMCA
to LAD (Fig. 6 & Video 7) . Subsequent to stent implantation a
4 x 10 non-compliant balloon was employed for post-dilatation. This
yielded improved blood flow in the LAD and diagonal. Notably, on
intravascular ultrasound (IVUS) imaging, the LM aneurysm was visualized
as a radiolucent shadow with layers and scintillating blood shadow
surrounding the stent struts and the stent appeared to dangle, creating
a potential nidus for thrombus formation (Fig. 7 & Video 8) .
In an endeavor to exclude the aneurysm, a 3.8 x 26 mm Graftmaster
covered stent (Coronary Stent Graft System, Abbott Vascular, Santaclara,
USA) was subsequently deployed from ostial LMCA, encompassing the LCx
and small sized RI extending up to the LAD/diagonal bifurcation,(Video 9) and post-dilated with a 5 x 8 mm non-compliant
balloon.
Finally, TIMI II flow in both LAD and diagonal was achieved(Fig. 8 & Video 10). Post procedure IVUS revealed bright echo
reflection due to the covered stent and echo drop out was observed
behind the multiple layers of stents (Fig. 9 & Video 11) . The
patient was discharged on aspirin, clopidrogrel, rivoraxaban and high
dose statin. At 3-month follow-up, angiography revealed TIMI III flow
into the LAD and its branches (Fig. 10 & Video 12) and
complete obliteration of the aneurysm. The patient’s symptoms improved,
and he was symptomatically better.