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Primary Stenting for Totally Occluded Left Main Coronary Artery with Acute Myocardial Infarction

- Operator: Seung-Whan Lee, MD / Myeong-Ki Hong, MD, PhD
Case Presentation
The patient was 50 year-old male. He presented to the emergency room with persistent chest pain for 3 hours. He had a 20 pack-year of smoking as a coronary risk factor. Baseline ECG showed ST elevation on precordial leads. Initial blood pressure was 60/30mmHg. He underwent emergent coronary angiography for primary PCI.
Baseline Coronary angiography
1. Coronary angiogram showed total occlusion in left main coronary artery with TIMI 1 flow
-- (Figure 1).
2. RCA was normal without intercoronary collaterals.
Procedure
An 8F sheath was inserted through both femoral artery and IABP was initially inserted through left femoral artery. The left coronary was engaged with an 8F Judkins catheter through right femoral sheath. Coronary angiogram showed total occlusion in shaft of left main coronary artery (LMCA) with TIMI 1 flow. At first, occluded LMCA was crossed with a 3.0x20 mm balloon without inflation to delineate accurate lesion. Following angiography showed totally occluded LMCA with TIMI 2 flow (Figure 2). The lesion was stented with a 4.0x12 mm heparin coated Jo stent at 6 atm without predilatation (Figure 3). After stenting, angiography revealed indentation of mid portion of stent (Figure 4). Thus additonal high pressure dilatation was performed with the stent balloon at 12 atm (Figure 5). Final angiography showed well deployed stent in the LMCA shaft without residual stenosis or dissection and with the presence of TIMI 3 flow (Figure 6). The hospital course was uneventful after stenting.
marioar2004-12-07
i believe there is a thrombus image in the first angiogram..why not to treat it with some aspiration device first,?congratulations for your excellent result Mario Araya Chile
javed ali khan2005-03-25
wonderful work, congratulation seung!!
Debabrata Dash2005-04-09
congrata for such a nice result.Dont you think that suction of thrombus prior to stenting would have been a better idea?I should have loved to do IVUS to find out stent apposition and expansion in this case.What is your opinion? DR D DASH TOYOHASHI HEART CENTER JAPAN
RAVI KUMAR2005-12-10
Considering the patient was extremely sick on entry to the Cath lab(BP60/30) I dont think there would have been time for any other Procedure except completing the Stenting , which the Operators have accomplished in double quick time. MAybe in a less unstable situation there would be time for Aspiration of thombus as the First procedure. Neverthless all credit for a successful Rescusitation by the Cath lab team. I would be interested to know what Javed thinks. DR R.RAVI KUMAR ,CHENNAI INDIA
Zhonghan Ni2007-11-02
Dr lee and Dr Hong:another question:Don't treat AMI patients with platelet llBlllA inhibitors or aspiration catheter,especially as so severe case,why? and how about the result of follow-up? thank for your reply.
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