[CLINICAL INFORMATION] Patient initials or identifier number. No Name Relevant clinical history and physical exam. A male patient, possibly around age 50, experienced out-of-hospital cardiac arrest and was sent to out hospital by EMT for further treatment. Spontaneous circulation was regained after defibrillation for ventricular fibrillation. High-dose inotropics were needed. The police was finding his family. Emergent CT scan and coronary angiography were arranged but ECMO support was not available at that time. The condition and timing were both critical for further intervention. Relevant test results prior to catheterization. Moderate metabolic acidosis was noted during CPCR and was corrected with sodium bicarbonate. The ECG during spontaneous circulation could not tell if there would be acute coronary syndrome with cardiogenic shock or not. The CT showed no intracranial hemorrhage, aortic dissection, or other internal bleeding. The sugar level was 375mg/dL, creatinine level was 1.1 mg/dL with normal electrolytes, hemoglobin was 14.2g/dL, WBC was 11640/mcL, and PT/PTT was normal. Relevant catheterization findings. The coronary angiography by JL4 diagnostic catheter showed Left main: Patent; LAD: mid 90% stenosis, looking like unstable plaque; LCx: Patent; The RCA could not be found by using JR4 diagnostic catheter. Although the LCx supplied a large territory, aortography was performed soon to identify whether RCA could be the culprit vessel or not. The aortography showed high take-off of the RCA from left coronary cusp. The RCA was identified more clearly with mid long critical stenosis. [INTERVENTIONAL MANAGEMENT] Procedural step. The culprit lesion was thought to be RCA. I chose a 7Fr Medtronic JL4 guiding catheter and adjusted it approaching RCA os. The mid RCA became totally occluded. A Sion wire was passed to distal RCA without much difficulty and thrombosuction was performed with a 7Fr Thrombuster, without thrombus took out. There was still no flow, so balloon dilatation was performed with a Sprinter 2.0×20mm, and flow was gained with a long critical lesion noted. Stent positioning was difficult due to limited support of the guiding catheter. A Medtronic Integrity bare metal stent 3.0×30mm and another Medtroic Integrity 3.0×26mm stent were deployed to cover the whole lesion at mid RCA, with TIMI-3 flow. The blood pressure improved but high-dose inotropics were still necessary. There was another tight lesion at mid LAD and the patient was under shock status. Since JL4 was used for RCA intervention, a second look for LAD was performed immediately, which showed total occlusion at mid LAD, distal to the tight lesion, suspecting post-stenotic spasm or distal thromboembolism. The sion wire was passed to distal LAD soon but the Thrombuster could not cross the lesion. After wiring another Sion Blue wire to diagonal branch, Balloon dilatation with Sprinter 2.0×20mm to the tight lesion was performed and TIMI-3 flow was achieved, with the distal occlusion disappeared. A MultiLink-8 3.5×28 bare metal stent was deployed with good final blood flow and improving hemodynamics. Besides, IABP was set for hemodynamic support. (figure present). Case Summary. For coronary intervention, making a clear diagnosis is always the key. There would be not only one lesion in an emergent ACS patient and lesions are not always easily to be accessed to. RCA from left coronary cusp is not so rare. Under strong inotropics, the coronary lesion would possibly not as stable as seen in the diagnostic angiography. The patient was discharged 32 days later without recovery of brain. It was a pity that socio-economic problem took place after life-saving, but I could only try my best to keep saving lives. Life is struggling and interventionist should be prepared. (figure present).
Chiang, L.-T. (2016). TCTAP C-010 A Confusing Treatment for a Patient with Acute Coronary Syndrome. Journal of the American College of Cardiology, 67(16), S85–S86. https://doi.org/10.1016/j.jacc.2016.03.212