PMC8556128_01
(a) ECG on presentation for the current admission showing ST segment elevation in V3-V6. (b) Initial angiogram on presentation in 2008. The patient had presented with an inferior wall myocardial infarction and underwent primary PCI of the RCA and subsequent staged PCI of the LAD one month later. (c) Angiogram after staged PCI of the LAD using 3.5 mm x 28 mm Cypher stent in the proximal segment of the LAD and overlapping 3 mm x 28 mm and 2.75 mm x 18 mm Cypher stents in the mid to distal LAD (stent locations marked with red brackets). (d) NSTEMI in 2011 secondary to thrombotic diagonal lesion which was ultimately treated with 2.5 mm x 12 mm Xience stent. Coronary angiogram revealed PSS in the proximal and distal LAD (red arrows).
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Electrocardiography (ECG) revealed ST elevation in leads V3-V6 (Figure 1(a)). He thereafter underwent staged PCI of the circumflex and subsequent staged PCI of the left anterior descending artery (LAD) using a 3.5 mm x 28 mm Cypher stent in the proximal segment and overlapping 3 mm x 28 mm and 2.75 mm x 18 mm Cypher stents in the mid to distal LAD (Figures 1(b) and 1(c)). The final angiogram revealed PSS in the proximal and distal LAD (Figure 1(d)).
(a) 3 months later, also in 2011, the patient presented with chest pain after clopidogrel interruption prior to surgery. He was found to have acute stent thrombosis in the mid LAD and second diagonal artery. Patient was treated with angioplasty and 3.5 mm x 15 mm BMS in mid LAD. A BMS was used due to the need for an upcoming surgery. Again, PSS was seen in the proximal and distal LAD (red arrows). (b) In 2013, the patient presented with an anterior STEMI and was found to have late stent thrombosis of the proximal LAD at site of previously identified PSS. The proximal LAD lesion was treated with angioplasty, and a 2.5 mm x 23 mm BMS was placed in the distal LAD. (c) PSS was noted in the proximal LAD on final angiogram (red arrow).
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Again, PSS was noted in the proximal and distal LAD (Figure 2(a)). In 2013, the patient presented with anterior STEMI and was found to have late stent thrombosis of his proximal LAD, at the site of previous PSS (Figure 2(b)). PSS was noted in the proximal LAD on final angiogram (Figure 2(c)).
(a) During the index procedure, coronary angiogram revealed acute stent thrombosis of proximal LAD and stent fracture with aneurysm formation at site of previously identified PSS. (b) Failed attempt at advancing wire beyond fractured stent in the proximal LAD, outline the coronary aneurysm. (c) Successful crossing of Cypher stent in proximal LAD on a third attempt given recurrent symptoms. (d) Final coronary angiogram with the inability to establish TIMI 3 flow in distal LAD.
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ECG changes, the cardiac catheterization laboratory was activated. Emergent coronary angiography demonstrated acute stent thrombosis of the proximal LAD at the site of previous PSS, with evidence of stent fracture and aneurysm (Figure 3(a)). The patient initially presented to an outside hospital, and despite multiple attempts, the lesion could not be wired due to the fracture and aneurysm (Figure 3(b)). The patient was brought back a few hours later due to recurrent symptoms with successful placement of DES; however, his procedure was complicated by no reflow and overall unsuccessful revascularization (Figures 3(c) and 3(d)).