Abed Dehnee MD, Rajiv Patel MD, Dan Tsyvine MD, Edo Kaluski, MD Massive Coronary Thrombosis Treated by Urgent Left Main, LAD & LCX Stenting Abed Dehnee MD, Rajiv Patel MD, Dan Tsyvine MD, Edo Kaluski, MD
I have no real or apparent conflicts of interest to report. Abed E. Dehnee, MD I have no real or apparent conflicts of interest to report.
Case Presentation 52 y/o African American woman with known history of CAD (s/p recent PCI) presented to the ED with ACS. Seven weeks earlier she underwent PCI of proximal LAD, RCA and LCX using BMS at an outside hospital due to planned hysterectomy for bleeding fibroids, for which Plavix was recently discontinued.
Physical Exam VS: HR 110, BP 168/88; 98% 2L NC, R 24 Gen: very anxious, moderate distress due to chest pain HEENT: plethoric neck unable to assess JVD Chest: rapid breathing, accessory muscle use, b/l crackles Heart: tachycardia, regular S1 & S2, +S4 Abdomen: obese, transverse hysterectomy scar with areas of dehiscence Ext: 1+ bilateral LE pitting edema, palpable DP/PT
Laboratory Studies EKG: NSR, NSST changes TTE: EF 50% with anteroseptal hypokinesia CXR: Pulmonary edema Blood work: Tox screen: + Marijuana Initial Troponin 0.46 CK: 73 CK-MB: ND 130 91 24 11.1 393 10.7 667 4.6 21 0.9 34.7
Hospital Course The patient received ASA and SL NTG in the ED without significant relief of chest pain: 10/107/10 Cardiology was called due to acute coronary syndrome, persistent chest pain and slightly elevated troponin level She was started on IV heparin and IV Integrilin and taken to the cath lab
IABP was inserted, transferred to CCU on aggressive med Rx IABP was inserted, transferred to CCU on aggressive med Rx. CT surgery consult requested and CABG was planned.
Hospital Course On day 3 she developed abdominal pain, Her abdominal pain persisted, and ischemic colitis was suspected Antibiotics were started and surgery was consulted & recommended conservative management CT surgery declined CABG due to suspected ischemic colitis and cardiology was asked to perform PCI. In view of the above PCI was recommended.
PCI, LAD: *Pt on Heparin drip 1200 u/h & integrilin drip ACT 177, given Heparin 2000 U bolus, also received Prasugrel 60mg orally on the table, *6F XB 3.0 guide catheter, 190 cm Whisper wire
The lesion dilated with 2. 0X12 Apex balloon @ 12 ATM X 2. Promus 2 The lesion dilated with 2.0X12 Apex balloon @ 12 ATM X 2. Promus 2.5 X 12 DES deployed
PCI, LCX: Two Whisper wires crossed the lesion, LAD wire left in place, 2.0 X 12 Apex balloon dilated the lesion @ 12 ATM.
The patient suddenly started complaining of severe crushing chest pain The patient suddenly started complaining of severe crushing chest pain. She became hypotensive with SBP in the 70’s
Repeat angiography showed LM, LAD and LCX thrombosis with probable proximal LAD dissection.
Heparin 3000 U bolus and two extra Integrilin boluses given, while the drip continued. Another Heparin bolus 2000 U given. A 2.0 X 23 Mini Vision BMS was deployed in the mid LAD @ 12 ATM
Repeat angiography showed good mid LAD results Repeat angiography showed good mid LAD results. However, a large filling defect in the LM and Prox LAD
A Promus 2.5 X 23 DES deployed in the prox LAD @ 13 ATM
Repeat angiography showed good LAD results Repeat angiography showed good LAD results. However, with a large filling defect in the LM
The LM stented with a Promus 2.5 X 15 DES deployed @ 17 ATM
Repeat angiography showed excellent results Repeat angiography showed excellent results. However with severe compromise of the LCX
An Apex 2. 0 X 20 used to dilate the proximal LCX An Apex 2.0 X 20 used to dilate the proximal LCX. Taxus DES deployed @ 13 ATM
An Apex 2. 0 X 20 used to dilate the proximal LCX and then a Taxus 2 An Apex 2.0 X 20 used to dilate the proximal LCX and then a Taxus 2.5 X 24 DES deployed @ 13 ATM
Apex 3.5 X 12 Balloon was used for post dilatation in the LM
Repeat angiography showed excellent flow in both vessels
The patient is now chest pain free The patient is now chest pain free. BP 111/47, HR 70’s, SpO2 100% ACT 237. Transferred to CCU in stable condition.
Hospital Course The patient tolerated this procedure well despite the complication. No bleeding issues post procedure and IABP removed She was discharged from the hospital 2 days post intervention Has followed up in DOC, compliant with meds ASA 325 mg/d - Lantus Insulin Prasugrel 10mg/d - Furosemide 40 mg/d Atorvastatin 80 mg/d - Valsartan 160 mg/d Metoprolol XL 50 mg/d
Troponin Trend PCI
Discussion- Causes Potential contributing mechanisms of massive coronary thrombosis: Retrograde dissection from LAD, LCX or both Wire related dissection Suboptimal anticoagulation Massive embolization from guiding catheter tip
Discussion- Treatment In case of dissection: stent the dissection! In case of suboptimal antiplatelet & anticoagulant therapy: Optimizing anticoagulation & anti-platelet therapy (monitor ACT, make sure IV is working) Attempt to aspirate thrombus
Follow up Patient was seen by cardiology and PCP in the office when she reported no active issues and compliance with medications. She reported feeling fairly well while doing usual daily activities on a recent telephone follow up.