Multiple coronary artery thrombosis in a 41-year-old male patient presenting with ST-segment elevation myocardial infarction

Simultaneous occlusion of multiple epicardial coronary arteries is an uncommon finding in patients presenting with ST-segment elevation myocardial infarction (STEMI). We describe a 41- year-old male Asian patient who presented with inferior and anterior STEMI complicated by cardiogenic shock and frequent life-threatening ventricular arrhythmias. The patient was subsequently found to have acute occlusion of the proximal right coronary artery (RCA) and proximal left anterior descending coronary artery (LAD). The patient was treated with primary percutaneous coronary interventions for RCA and LAD, and intra-aortic balloon pump placement showed excellent results. Based on the available literature, early PCI for this very rare condition is paramount for patient survival.     

Percutaneous transluminal coronary angioplasty of distal lesions: comparison of results with proximal lesions.

The results of percutaneous transluminal coronary angioplasty (PTCA) of 57 distal lesions were compared with 55 proximal lesions in 42 patients, aged 31 to 66 years (mean +/- SD: 51 +/- 9 yrs). Twenty nine (69%) had multivessel and 13 (31%) single vessel disease. The lesions classified as distal were located in left anterior descending (LAD) artery beyond the origin of second diagonal (D2), left circumflex (LCx) after the main obtuse marginal (OM) and right coronary artery (RCA) after the origin of acute marginal branch. Also included in this category were lesions in the second diagonal and obtuse marginal branches, two centimeters from their origin and stenosis in the posterior descending and posterolateral left ventricular branches of RCA. Out of 57 distal lesions 18 were 'complex' because of tandem location (5 patients), ulceration (6 lesions) and intraluminal thrombi (2 lesions). There was no significant difference in the mean luminal diameter stenosis between distal and proximal lesions, before and after PTCA. The primary success rate of angioplasty was 89.5% for the distal and 94.5% for the proximal lesions (P = NS). Inability to position the balloon across the lesion accounted for more failures in distal (3) compared to proximal (1) location. There were no major complications. Our results show that PTCA of distal lesions can be performed with a high rate of success, which is comparable to those with classical proximal lesions in the same patients.     

Acute myocardial infarction showing total occlusion of right coronary artery and thrombus formation of left anterior descending artery

A 33-year-old Japanese man had an attack of chest pain associated with ST-segment elevation in the inferolateral leads on his electrocardiogram. Emergency coronary angiography showed total obstruction in the mid right coronary artery (RCA) and a movable thrombus in the proximal left anterior descending artery (LAD). We performed emergency percutaneous transluminal coronary angioplasty (PTCA) for the RCA lesion. The operation was successful and we then conducted intracoronary thrombolysis (ICT) with tisokinase 6,400,000 IU for the LAD thrombus. Its size was reduced by ICT. He had an uneventful hospital course. After 1 month, repeat coronary angiography showed no significant stenosis in the RCA nor thrombus in the LAD. A coronary spasm provocation test was performed using acetylcholine. Coronary spasm in the LAD was induced by an intracoronary injection of 100 microg acetylcholine. In this case, we observed a unique condition suggesting simultaneous double coronary artery occlusion.     

Intracoronary thrombus formation causes focal vasoconstriction of epicardial arteries in patients with coronary artery disease

BACKGROUND. Experimental studies have demonstrated that intracoronary platelet aggregation and thrombus formation may induce marked vasoconstriction of epicardial arteries with endothelial injury. METHODS AND RESULTS. To examine the effects of intracoronary thrombus formation on coronary vasomotor tone of human epicardial arteries in vivo, we studied 15 patients who developed intracoronary thrombi adherent to the guide wire during balloon dilatation. Epicardial artery luminal area was evaluated by quantitative coronary angiography proximal and distal to the site of intracoronary thrombus formation and in a reference vessel before and after thrombus formation as well as after intracoronary injection of 0.2-0.3 mg nitroglycerin. All artery segments distal to the site of thrombus formation showed vasoconstriction with a luminal area reduction of -27.4 +/- 17.1% (p less than 0.001), whereas proximal vessel segments and reference vessels not manipulated during percutaneous transluminal coronary angioplasty did not demonstrate any significant luminal area changes during thrombus formation. Angiographic measurements after advancing the guide wire with the adherent thrombus (performed in six of the 15 patients) revealed in all patients that vasoconstriction did develop at a new site distal to the thrombus persistence of the initial vasoconstriction now residing proximal to the thrombus. Thus, there was a sequential association between thrombus formation and subsequent distal vasoconstriction. Intracoronary injection of nitroglycerin abolished the thrombus-induced vasoconstriction. No significant luminal area changes were observed in 20 patients without angiographic evidence of intracoronary thrombus formation. CONCLUSIONS. Intracoronary thrombus formation during percutaneous transluminal coronary angioplasty causes focal vasoconstriction of epicardial arteries in patients with coronary artery disease. Although caution must be advised in the extrapolation of this phenomenon, which was observed in a manipulated artery during coronary angioplasty, the vasoconstrictor response to intracoronary thrombus formation in vivo may play an important role in the dynamic mechanisms of acute coronary heart disease syndromes.     

Thrombus-related focal in-stent restenosis after everolimus-eluting stent implantation

A 60-year-old man who had received repeated angioplasty for silent ischemia was suspected to have restenosis based on radioisotope imaging (exercise-RI) findings 6 months after everolimus-eluting stent (EES) implantation (3.5 × 28, 3.5 × 28, 3.0 × 18 mm). The stents had been implanted for chronic total occlusion of the right coronary artery (RCA), and the patient was on continuous dual antiplatelet therapy. Diagnostic angiography demonstrated in-stent restenosis in the proximal RCA, which was treated by optical coherence tomography (OCT)-guided cutting balloon angioplasty with distal protection. OCT findings of the stenotic segment before angioplasty showed that the lesion had complex features. The lesion was successfully dilated, and whitish material obtained by a distal protection device was composed of fibrin thrombi with neutrophils and small pieces of mature fibrocellular neointima. The mechanisms and patterns of restenosis after EES placement have not been well clarified. This case may reflect a restenosis pattern (i.e., asymptomatic, focal, and thrombi-related) in the era of the newer generation of drug-eluting stents.     

Correlation of remote ST segment depression and coronary anatomy during acute coronary occlusion

BACKGROUND: The appearance of remote ST segment depression (RSTD) on an electrocardiogram (ECG) is associated with more extensive infarction and a worse clinical outcome than when RSTD is absent. OBJECTIVE: To determine whether RSTD predicts coronary anatomy during acute coronary occlusion. It was hypothesized that RSTD is associated with the occlusion of a proximal lesion, an extensive artery and an artery without distal collateralization. PATIENTS AND METHODS: In 113 consecutive patients with single vessel disease undergoing percutaneous transluminal coronary angioplasty (PTCA), 12-lead ECGs (recorded at baseline and during balloon inflation) and angiographical data were analyzed independently. Patients with ST segment elevation in the primary territory and RSTD (greater than 1 mm ST depression at 80 ms after the J point) (group A) were compared with patients without RSTD (group B). Proximal lesions were defined as lesions located in the segments proximal to the acute marginal branch, first diagonal artery or first obtuse marginal branch. An extensive right coronary artery (RCA) was one that supplied the posterolateral wall; an extensive left anterior descending (LAD) artery was one that supplied the inferoapical wall; and an extensive circumflex artery was one that supplied the posterior descending artery. RESULTS: Fifty-four patients (48%) had PTCA of the proximal vessels, 43 patients (38%) had extensive target vessels and 11 patients (9.7%) had collaterals. Target vessels included 33% in RCA, 44% in LAD artery and 23% in circumflex artery. Forty-five patients (40%) developed RSTD during balloon inflation (group A). Patients in group A were more likely to have extensive vessels on the angiogram than those in group B (group A 49%, group B 31%; P=0.05). None of the patients in group A had collaterals to the culprit artery, while 16% of patients in group B did (P=0.003). The two groups were not significantly different with respect to the number of proximal lesions (group A 58%, group B 42%; P=0.08). Analysis performed according to the target artery revealed that RSTD was associated with occlusion of an extensive RCA during RCA occlusion (extensive RCA in group A 100%, group B 57%; P=0.006). For the LAD artery, RSTD was associated with proximal lesions (group A 74%, group B 41%; P=0.02) and absence of collaterals (group A 100%, group B 74%; P=0.01). CONCLUSIONS: During acute coronary occlusion, the presence of RSTD on 12-lead ECG was specific for the absence of collaterals. The presence of RSTD during RCA occlusion was strongly associated with an extensive RCA, suggestive of posterolateral wall ischemia. During LAD artery occlusion, the presence of RSTD was associated with proximal occlusion, which resulted in ischemia of the LAD artery and the major diagonal artery territories.     

Combined distal embolization protection and rheolytic thrombectomy to facilitate percutaneous revascularization of totally occluded saphenous vein grafts.

Totally occluded saphenous vein grafts are difficult to treat percutaneously with a higher likelihood of distal embolization and slow-flow or no-reflow during percutaneous interventions. The PercuSurge system, which utilizes a distal balloon occlusive device, has been shown to improve clinical outcomes during saphenous vein graft (SVG) interventions. This device may not be optimal in the setting of heavy thrombus or debris burden, a situation frequently encountered in totally occluded SVGs. Rheolytic thrombectomy facilitates percutaneous interventions by effectively removing intraluminal thrombus and debris but lacks distal embolization protection. We report our experience with the synergistic use of balloon-based distal embolization protection (PercuSurge) and rheolytic thrombectomy (AngioJet) to optimize percutaneous revascularization of totally occluded SVGs.     

Proximal right coronary artery diverticulum resulting in recurrent distal embolization

This is a case of a right coronary artery (RCA) diverticulum. We highlight the complications of distal embolization and recurrent myocardial infarctions (MI), and the successful closure with a covered stent. A 33-year-old Khat user experienced non-ST elevation MI (non-STEMI) 3 times over 2 years. His first cardiac catheterization showed a proximal RCA ulceration. The last catheterization revealed a proximal RCA diverticulum containing a thrombus, and a thrombus at the distal PDA. A covered Jomed? stent (Jomed International AB) was placed into the proximal RCA, closing the diverticulum, and preventing future embolizations. Patient's atherosclerotic ulceration led to diverticular disease that resulted in blood flow stasis, thrombi, distal embolization, and repeat acute coronary events.     

Acute myocardial infarction associated with myocardial bridging in a young adult

A 28-year-old man was admitted because of chest pain. Emergency coronary angiography showed a massive thrombus in the proximal segment and another occlusive thrombus in the distal segment of the left anterior descending artery. He was treated with thrombolytic therapy. Repeat coronary angiography showed disappearance of the thrombi in the proximal and distal segments and obvious myocardial bridging in the mid segment. Intravascular ultrasound revealed an atherosclerotic plaque in the segment immediately proximal to the myocardial bridging, but did not reveal any plaque within or distal to the site. He was discharged 12 days later.     

Physiological impact of CTO recanalization assessed by coronary pressure measurement: A case report

In this case report, physiological changes of myocardial perfusion in the collateral recipient right coronary artery (RCA) and the collateral donor left anterior descending artery (LAD) with an intermediate lesion were assessed using intracoronary pressure measurement, before and after revascularization of chronic total occlusion (CTO). A 44‐year‐old male was referred for a catheter examination due to silent myocardial ischemia. An invasive coronary angiogram revealed diffuse narrowing of the RCA with focal occlusive segments in addition to intermediate stenosis in the LAD. A well developed collateral channel from the LAD to the RCA was also confirmed. Fractional flow reserve (FFRmyo) of the LAD before opening the RCA was 0.81. After successful revascularization of the RCA, FFRmyo of the LAD and the RCA were measured with and without an RCA balloon occlusion. Because collateral fractional flow reserve (FFRcoll) of the RCA could be regarded as FFRmyo before revascularization, FFRmyo of the RCA increased from 0.67 to 0.90, meaning a 23% increase of maximum flow by intervention. Interestingly, improvement of FFRmyo of the LAD from 0.81 to 0.93 was also observed, which means a 12% increase of maximum flow. Coronary steal in the LAD was reconfirmed by dramatic worsening of FFRmyo from 0.93 to 0.77 by an RCA balloon occlusion. This phenomenon may be explained by an immediate recruitment of collateral channels. This case clearly demonstrated that CTO opening improves perfusion in not only myocardium supplied by the CTO vessel, but also in that which is supplied by a contralateral collateral donor artery. © 2013 Wiley Periodicals, Inc.     

Successful fenestration using a chronic total occlusion-dedicated guidewire in a patient with catheter-induced dissection of the right coronary artery

Guiding catheter-induced coronary artery dissection is a rare, but hazardous complication of percutaneous coronary intervention (PCI) and is associated with the potential risk of impairment of coronary blood flow. Therefore, occurrence of this complication mandates a prompt revascularization procedure. A 68-year-old female patient with acute myocardial infarction caused by total occlusion of the proximal right coronary artery (RCA) underwent PCI. After revascularization by thrombus aspiration, catheter-induced dissection of the ostium of the right coronary artery (RCA) occurred when the guiding catheter and guidewire were accidentally removed. An attempt to engage the guiding catheter and guidewire into the true lumen failed because of total occlusion of the right coronary ostium. A chronic total occlusion (CTO)-dedicated guidewire was then used to create a fenestration of the intimal flap, and after it penetrated into the distal true lumen, a low-profile balloon catheter was dilated, and coronary flow from the false to the true lumen was established. After balloon dilatation, stents were deployed at both the dissection site and in the distal lesion. The final angiogram revealed restoration of coronary blood flow. We propose that application of a CTO-dedicated guidewire to create a fenestration of the intimal flap in the region of the coronary dissection is a feasible and effective alternative to conventional procedures.     

PCI结合冠脉内溶栓治疗右冠状动脉急性闭塞13例

目的：总结右冠状动脉（RCA）内注射大剂量尿激酶结合球囊扩张挤压的方法处理13例RCA急性血栓性闭塞的临床资料，评价其效果和安全性。方法：回顾性分析18例急性下壁心肌梗死病人的临床资料，在RCA近、中段急性闭塞部位急诊植入18枚普通支架后，闭塞的血管完全开通。但是，其中13例病人出现血栓栓塞支架以远的RCA主干，单纯球囊低压扩张挤压（4～6atm）等机械方法不能粉碎血栓，开通血管，遂通过导管向RCA注射50万U尿激酶（20min），再用球囊扩张挤压血栓；如果血栓不能被溶解粉碎，再注射尿激酶50万U，重复球囊扩张挤压。结果：6例接受冠脉内注射尿激酶50万U，其他7例接受尿激酶100万U，RCA血流恢复TIMI3级，远端RCA主干未见栓塞征象。13例病人住院期间无出血等并发症，随访2～20（10±8）个月未见发作心脏事件。结论：尤其是在没有Angiojet流体溶血栓吸引术或血管远端保护装置情况下，冠脉内注射大剂量尿激酶结合球囊扩张挤压血栓，不失为一种解决急性血栓性病变的简便易行而安全的补救方法。     

Unusual balloon rupture during direct stenting with a TaxusExpress stent in a venous graft complicated by vessel rupture: a device-related fatal event

A 70-year-old male with a prior coronary artery bypass operation presented with increasing episodes of chest pain. Coronary angiography revealed severe disease of the left anterior descending artery (LAD), CX, and RCA. A left internal mammary artery to LAD was patent. A jump venous graft, with four distal anastomoses, had two significant stenoses. Percutaneous coronary intervention with distal protection, and direct stenting with a drug-eluting stent, was planned. A 3.00 x 16 mm TaxusExpress (Boston Scientific) was used. At an inflation pressure of 10 atm the stent balloon seemed to extend 20 mm proximally with a diameter of 4.5 mm, and the balloon ruptured. Angiography showed rupture of the vessel proximal to the implanted stent, and the patient developed severe hypotension. The rupture was treated with a covered stent and pericardiocentesis was performed with evacuation of 600 mL blood. However, it was not possible to resuscitate the patient, who died due to severe pump failure and incessant ventricular fibrillation.     

Effect of coronary occlusion site on angiographic and clinical outcome in acute myocardial infarction patients treated with early coronary intervention

In acute myocardial infarction that is treated with thrombolysis, proximal coronary artery occlusion is associated with worse prognosis, irrespective of the infarcted artery. Primary percutaneous coronary intervention (PCI) is currently the treatment of choice for ST-segment elevation acute myocardial infarction. Therefore, we evaluated the prognostic significance of proximal versus distal coronary artery occlusion in patients with acute myocardial infarction that was treated with primary PCI. Between 1994 and 2001, patients with a first acute myocardial infarction that was treated with primary PCI were analyzed. A lesion was considered proximal if it was located proximal to the first diagonal branch in the left anterior descending coronary artery (LAD), the first marginal obtuse branch in the left circumflex coronary artery, and the first right acute marginal branch in the right coronary artery. Lesions distal of these side branches were considered distal. In total, 1,468 patients were analyzed. Left ventricular ejection fraction (LVEF) for proximal LAD lesions was lower than that for distal ones (37 +/- 11% vs 42 +/- 11%, p <0.0001). Adjusted relative risk of 3-year mortality for proximal versus distal LAD was 4.04 (95% confidence interval 1.95 to 8.38). In patients with infarcts related to the right or left circumflex coronary artery, no significant association between lesion location and LVEF or mortality was seen. No difference was seen in adjusted 3-year mortality between distal LAD and non-LAD-related infarcts (p = 0.145). In conclusion, our analysis shows that, even in patients with acute myocardial infarction that is treated with primary PCI, infarcts related to the proximal LAD have the worst 3-year survival and lowest residual LVEF compared with distal LAD or non-LAD-related infarcts.     

A pitfall of fractional flow reserve associated with the presence of collateral circulation

An 82-year-old man had a severe stenosis in the proximal left anterior descending artery (LAD) and an intermediate stenosis in the distal right coronary artery (RCA). The territory of mid to distal LAD was perfused via an angiographically well-developed collateral circulation from the distal RCA. Fractional flow reserve (FFR) in the distal RCA was 0.84. After successful coronary intervention for the proximal LAD, repeat FFR in the distal RCA was 0.96. In this case, the severity of the stenosis in the donor artery was overestimated by using FFR due to the presence of well-developed collateral circulation.     

Left main coronary artery arising from right sinus of Valsalva: a rare congenital anomaly associated with distal vasospasm

A 50 year-old female patient was admitted to our outpatient clinic with a two year history of chest pain and dyspnoea on exertion. Echocardiography revealed apical hypokinesia with an ejection fraction of 50% on the left ventricle. Coronary angiography revealed that the left main coronary artery was arising from the right sinus of Valsalva and than coursing posterior to the aorta. There were significant stenoses at the proximal right coronary artery (RCA) and the proximal left anterior descending coronary artery (LAD). The RCA lesion disappeared after intracoronary nitroglycerine administration, and the LAD lesion disappeared the next day when the patient was due to undergo percutaneous intervention. Stress myocardial perfusion scintigraphy revealed anteroseptal ischaemia consistent with reversible ischaemia.     

Potential risk of provisional stenting in left main coronary artery bifurcation in multivessel‐related acute coronary syndrome

We present a case of an elderly man suffering from an acute coronary syndrome (ACS) with preshock vital signs and remarkable ST–T wave depression in leads V4–V6, and ST elevation in lead aVR. Coronary angiography showed total occlusion of the right coronary artery (RCA) and impending occlusion in the distal left main coronary artery (LMCA) with a tandem lesion in the proximal left anterior descending artery (LAD). After insertion of an intra‐aortic balloon pump both the LAD and left circumflex artery (LCX) were dilated alternatively; and cross‐over stenting in the LMCA bifurcation was subsequently performed. However, total occlusion of the LCX occurred and it caused acute hemodynamic collapse and ventricular fibrillation storm. Immediate installation of percutaneous cardio‐pulmonary support system allowed stent deployment to be performed in the RCA and subsequent reopening of the LCX that led to a return to sinus rhythm. The patient recovered almost normal left ventricular wall motion and previous activity without any neurological deficit within 2 weeks. Provisional stenting in ACS in the LMCA bifurcation with multivessel disease has a potential risk of acute hemodynamic collapse; a planned two‐stent deployment strategy may assure a higher rate of safety in such cases. © 2011 Wiley‐Liss, Inc.     

Embolic protection devices

The limiting factor in coronary artery bypass surgery is the relatively rapid progression of atheromatous disease in the saphenous vein grafts. Greater than one-half of these vein grafts will fail by 10 years, and the risks associated with repeat coronary artery bypass surgery are significantly greater than that of the initial surgery. Yet, catheter-based interventional treatment of saphenous vein grafts is hindered by distal embolization of friable lipidrich plaque. This is one mechanism responsible for reduced antegrade flow (i.e., "no-reflow" phenomenon), including spasm of the distal microcirculation and platelet clumping. This complication increases the risk of a major adverse clinical event (i.e., myocardial infarction or late mortality). Distal protection devices are designed to provide protection of the distal microcirculation during percutaneous intervention. One device type is a balloon occlusive system that temporarily occludes the distal vessel during the intervention followed by the aspiration of liberated atheromatous and thrombotic material before it reaches the arteriolar and capillary bed. The other device type is a nonocclusive, filter-based system that preserves coronary blood flow through tiny pores, as low as 100 microns. Atheromatous and thrombotic material is trapped in the filter-based systems and then removed with the retrieval of the device through a retrieval catheter. This article discusses the current distal protective devices.     

体表心电图预测梗死相关动脉及部位的敏感性和特异性

目的总结体表心电图（ECG）判断ST段抬高心肌梗死（STEMI）患者的梗死相关动脉（IRA）的流程,确定其敏感性、特异性和准确性。方法入选896例STEMI患者。根据公认的ECG判断标准,制订相应流程,判断IRA及其具体部位,并与即刻冠状动脉造影对比,确定流程的敏感性、特异性和准确性。结果判断左主干病变的敏感性为100%、特异性99%和准确性99%;判断前降支病变的敏感性、特异性和准确性分别为99%、99%和99%,其中近段为84%、90%和88%,中远段为57%、94%和88%;判断回旋支病变的敏感性、特异性和准确性分别为64%、95%和91%;判断右冠状动脉病变的敏感性、特异性和准确性为89%、92%和91%,其中近段为51%、96%和88%,中远段为68%、92%和85%。结论本研究的流程可以准确判断左主干、前降支和右冠状动脉近段病变,但区分回旋支和右冠状动脉中远段病变时有一定限度。     

Multivessel acute coronary thrombosis and occlusion--an unusual cause of cardiogenic shock

A 44-year-old male was admitted with ST-elevation myocardial infarction and cardiogenic shock. Angiography revealed a left anterior descending artery (LAD) as well as right a coronary artery acute thrombotic occlusion and large mobile thrombi in the circumflex artery. He was treated mainly with multivessel thrombus aspiration and intra-aortic balloon insertion. Subsequent intravascular ultrasound a week later revealed mild disease of the LAD only. We suggest that in selected patients with cardiogenic shock, plaque rupture with resultant acute thrombosis in a single coronary artery may lead to low coronary perfusion pressure and consequent multivessel thrombus formation. Thrombus aspiration should be the main therapeutic modality in such unusual cases.