Post-Stent Very Proximal Left Anterior Descending Coronary
A 39-year-old male with recent onset angina was admitted to our department with an acute infero-lateral myocardial infarction. The patient had no prior cardiac medical history, except for episodes of chest pain in recent months. As a result of the chest pain, the patient performed a cardiac stress test, which was positive for ischemia. He did not have other cardiac risk factors and did not undergo further evaluation. Due to severe and prolonged chest pain on the day of admission, he presented to the emergency room where the electrocardiogram revealed Q-waves and S-T segment elevation in all three inferior leads with a first degree A-V block. The patient was treated with thrombolytic therapy (STK) with signs of successful reperfusion, after which the patient remained asymptomatic.
Laboratory studies showed a peak cardiac troponin-I of > 50 ng/ml and a creatine phosphokinase (CK) of 2,072 U/L with elevated homocysteine levels and reduced HDL levels. An echocardiogram performed two days after admission revealed mildly reduced left ventricular systolic function, segmental wall motion abnormalities and right ventricular dysfunction. In addition to the inferolateral infarct, the echocardiogram demonstrated a posterior and right ventricular infarct.
Eight days after admission the patient underwent coronary angiography that revealed two-vessel disease involving a severe stenosis in the mid-portion of the left anterior descending coronary artery (LAD) and of the distal right coronary artery (RCA) (Figure 1 A and B). There was also a 50-75% lesion in the ostial portion of the posterolateral artery. Primary stenting of both the mid-LAD and the distal RCA were successfully performed and plain balloon angioplasty of the ostial portion of the posterolateral artery (Figure 1B and 2B). There were no peri-procedural complications and the patient was discharged the next day on dual antiplatelet therapy (aspirin and clopidogrel), statins, beta-blockers and ACE inhibitors.
(Enlarge Image)
( A ) Left coronary angiogram showing a severe stenosis in the mid portion of the left anterior descending coronary artery (LAD); ( B ) Right coronary angiogram showing a severe stenosis in the distal portion of the right coronary artery (RCA).
(Enlarge Image)
( A ) Left coronary angiogram showing the final result following successful stenting (arrowheads) of the lesion in the mid portion of the left anterior descending coronary artery (LAD); ( B ) Right coronary angiogram following successful stenting of the lesion in the right coronary artery (RCA) (arrowheads).
Two months later the patient performed a routine stress test, which was positive for ischemia. Ten days after the exam, the patient experienced recurrent episodes of chest pain, shortness of breath and cold sweats. The symptomatic episodes became more frequent and three days later, the patient admitted himself to the hospital emergency room. An electrocardiogram on admission did not show any significant changes and cardiac enzymes were normal. Coronary angiography at this time revealed that all previous stents remained patent, but a pseudo-aneurysm had developed in the proximal portion of the LAD (Figure 3A) that compromised the proximal portion of the stent and the origin of the first diagonal branch (Figure 3B). Furthermore, there was a 90% lesion in the mid-RCA, proximal to the stent previously deployed (Figure 3C). Considering the perilous position of the pseudo-aneurysm and the unstable status of the patient, a debate ensued as to what type of intervention could be performed safely and with optimal long-term results.
(Enlarge Image)
( A , B ) Pseudo-aneurysm in the proximal portion of the left anterior descending coronary artery (LAD; arrowheads) that involves the proximal portion of the stent and the origin of the first diagonal branch. ( C ) Right coronary angiogram showing a severe stenosis in the mid-portion of the right coronary artery (RCA; proximal to the stent; arrowhead).
A 39-year-old male with recent onset angina was admitted to our department with an acute infero-lateral myocardial infarction. The patient had no prior cardiac medical history, except for episodes of chest pain in recent months. As a result of the chest pain, the patient performed a cardiac stress test, which was positive for ischemia. He did not have other cardiac risk factors and did not undergo further evaluation. Due to severe and prolonged chest pain on the day of admission, he presented to the emergency room where the electrocardiogram revealed Q-waves and S-T segment elevation in all three inferior leads with a first degree A-V block. The patient was treated with thrombolytic therapy (STK) with signs of successful reperfusion, after which the patient remained asymptomatic.
Laboratory studies showed a peak cardiac troponin-I of > 50 ng/ml and a creatine phosphokinase (CK) of 2,072 U/L with elevated homocysteine levels and reduced HDL levels. An echocardiogram performed two days after admission revealed mildly reduced left ventricular systolic function, segmental wall motion abnormalities and right ventricular dysfunction. In addition to the inferolateral infarct, the echocardiogram demonstrated a posterior and right ventricular infarct.
Eight days after admission the patient underwent coronary angiography that revealed two-vessel disease involving a severe stenosis in the mid-portion of the left anterior descending coronary artery (LAD) and of the distal right coronary artery (RCA) (Figure 1 A and B). There was also a 50-75% lesion in the ostial portion of the posterolateral artery. Primary stenting of both the mid-LAD and the distal RCA were successfully performed and plain balloon angioplasty of the ostial portion of the posterolateral artery (Figure 1B and 2B). There were no peri-procedural complications and the patient was discharged the next day on dual antiplatelet therapy (aspirin and clopidogrel), statins, beta-blockers and ACE inhibitors.
(Enlarge Image)
( A ) Left coronary angiogram showing a severe stenosis in the mid portion of the left anterior descending coronary artery (LAD); ( B ) Right coronary angiogram showing a severe stenosis in the distal portion of the right coronary artery (RCA).
(Enlarge Image)
( A ) Left coronary angiogram showing the final result following successful stenting (arrowheads) of the lesion in the mid portion of the left anterior descending coronary artery (LAD); ( B ) Right coronary angiogram following successful stenting of the lesion in the right coronary artery (RCA) (arrowheads).
Two months later the patient performed a routine stress test, which was positive for ischemia. Ten days after the exam, the patient experienced recurrent episodes of chest pain, shortness of breath and cold sweats. The symptomatic episodes became more frequent and three days later, the patient admitted himself to the hospital emergency room. An electrocardiogram on admission did not show any significant changes and cardiac enzymes were normal. Coronary angiography at this time revealed that all previous stents remained patent, but a pseudo-aneurysm had developed in the proximal portion of the LAD (Figure 3A) that compromised the proximal portion of the stent and the origin of the first diagonal branch (Figure 3B). Furthermore, there was a 90% lesion in the mid-RCA, proximal to the stent previously deployed (Figure 3C). Considering the perilous position of the pseudo-aneurysm and the unstable status of the patient, a debate ensued as to what type of intervention could be performed safely and with optimal long-term results.
(Enlarge Image)
( A , B ) Pseudo-aneurysm in the proximal portion of the left anterior descending coronary artery (LAD; arrowheads) that involves the proximal portion of the stent and the origin of the first diagonal branch. ( C ) Right coronary angiogram showing a severe stenosis in the mid-portion of the right coronary artery (RCA; proximal to the stent; arrowhead).
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