1. 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

2. 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.

3. 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.

4. 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

5. 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

6. Hospital Course
The patient received ASA and SL NTG in the ED without significant relief of chest pain: 10/107/10
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

10. 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.

11. 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.

12. 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

13. The lesion dilated with 2. 0X12 Apex balloon @ 12 ATM X 2. Promus 2
The lesion dilated with 2.0X12 Apex 12 ATM X 2. Promus 2.5 X 12 DES deployed

14. PCI, LCX: Two Whisper wires crossed the lesion, LAD wire left in place, 2.0 X 12 Apex balloon dilated the 12 ATM.

15. 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

16. Repeat angiography showed LM, LAD and LCX thrombosis with probable proximal LAD dissection.

19. 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 12 ATM

20. 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

21. A Promus 2.5 X 23 DES deployed in the prox LAD @ 13 ATM

22. Repeat angiography showed good LAD results
Repeat angiography showed good LAD results. However, with a large filling defect in the LM

23. The LM stented with a Promus 2.5 X 15 DES deployed @ 17 ATM

24. Repeat angiography showed excellent results
Repeat angiography showed excellent results. However with severe compromise of the LCX

25. 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 13 ATM

26. 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 13 ATM

27. Apex 3.5 X 12 Balloon was used for post dilatation in the LM

28. Repeat angiography showed excellent flow in both vessels

29. The patient is now chest pain free
The patient is now chest pain free. BP 111/47, HR 70’s, SpO2 100% ACT Transferred to CCU in stable condition.

30. 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

31. Troponin Trend
PCI

32. 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

33. 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

34. 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.