PMC10166827_01
ECG in the ER before the coronary angiogram. ECG showing AF, complete heart block, junctional escape rhythm, and ST-segment elevation in leads II, III, aVF, and V3R-V5R.
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F1
An electrocardiogram showed atrial fibrillation (AF), complete heart block, junctional escape rhythm, and ST-segment elevation in leads II, III, aVF, and V3R-V5R (Figure 1).
Coronary angiogram. The initial view of the coronary angiogram in (A-C) revealing a normal left coronary system and an embolism in the proximal right coronary artery (dark arrow): (A) Cranial 30, (B) RAO 30 + Caudal 30, (C) LAO 40. (D) Hourglass sign of balloon angioplasty. (E) Embolus in the proximal right coronary artery (dark arrow). (F) Right coronary angiogram showing TIMI 3 blood flow after the intervention.
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F2
An emergency coronary angiogram showed a total occlusion of the proximal right coronary artery (RCA) with a globular filling defect without any collateral vessels from the left coronary system (Figure 2). Then, we used a Sprinter balloon of different sizes (2.0 x 20 mm and 2.5 x 15 mm) (Medtronic, USA), which successively dilated the lesion, and an hourglass sign was revealed (Figure 2). TIMI 1 and the embolus ran deeper into the RCA (Figure 2). To make the characteristics of the embolus clear, we decided to perform intravenous ultrasound (IVUS) (Boston Scientific, USA).
Intravenous ultrasound (IVUS). IVUS showing calcification and posterior echo attenuation in the middle RCA (white arrow).
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F3
IVUS showed calcification and posterior echo attenuation in the mid-RCA (Figure 3).
Angioguard umbrellas in both carotid arteries.
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F4
Angioguard (6 mm) umbrellas (Cordis, USA) were inserted in both carotid arteries through an 8-Fr MPA catheter (Cordis, USA) (Figure 4). A 2.5 x 15 mm Sprinter balloon was successfully passed through the lesion and was inflated to 4 atm.
Lower limb artery angiography showing a filling defect (dark arrow) in the right peroneal artery.
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F5
Fortunately, we found that the embolus was brought to the right peroneal artery (Figure 5).
ECG after the procedure. ECG showing AF, and premature ventricular beats.
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F6
An electrocardiogram after the procedure revealed that the ST segment had returned to baseline and no significant Q wave was detected in the inferior leads (Figure 6).
(A) Photograph of the retrieved embolus: gray globular tissue with a diameter of 4 mm. (B) Photomicrograph of the embolus. Hematoxylin and eosin staining. At the center of the embolus is fibrinoid necrosis with a few mixed red blood cells, and the surrounding is a thick layer of fibrotic tissue with hyaline degeneration and peripheral calcification.
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F7
Fibrinoid necrosis developed at the center of the embolus with a few mixed red blood cells, and surrounding it was a thick layer of fibrotic tissue with hyaline degeneration and peripheral calcification (Figure 7).