AiAcute inn--stent tstent thbihrombosis postost--PCI iPCI

A iA i h b ih b iAcute inAcute in--stent thrombosis stent thrombosis PCI iPCI ipostpost--PCI in acute PCI in acute

ddcoronary syndromecoronary syndromeTangshan Gongren HospitalTangshan Gongren Hospital

唐山工人医院唐山工人医院唐山工人医院唐山工人医院

Hebei Medical University, PR.ChinaHebei Medical University, PR.ChinaZh Ji MDZh Ji MDZheng Ji, MDZheng Ji, MD

HistoryHistoryHistoryHistory

Male, 70yrsMale, 70yrsChief complaintChief complaint：：Onset of chest pain 3 daysOnset of chest pain 3 daysChief complaintChief complaint：：Onset of chest pain 3 days Onset of chest pain 3 days Admitted timeAdmitted time：：20102010--1111--11，，0909：：0000Risk factors: smoking history 50 years, 20 Risk factors: smoking history 50 years, 20 cigarette/daycigarette/dayc g e e/d yc g e e/d y

ExaminationsExaminationsExaminationsExaminations

ECG in OutECG in Out--patientpatient DepartmentDepartment


ECG in CCU ECG in CCU


Emergency UCG in bedsideEmergency UCG in bedside（（20102010--1111--11）：）：LA33mm,LV48mm,EF59%, Ventricular LA33mm,LV48mm,EF59%, Ventricular , , ,, , ,wall motion normalwall motion normal 。。At admitted time and before firstAt admitted time and before firstAt admitted time and before first At admitted time and before first PCI,Myocardial biomarkers are normal.PCI,Myocardial biomarkers are normal.

DiagnosisDiagnosisDiagnosisDiagnosis

Coronary heart diseaseCoronary heart diseaseCoronary heart diseaseCoronary heart diseaseacute coronary syndromeacute coronary syndrome

regimenregimenregimenregimenD thD thDrug therapyDrug therapy：：Plavix Plavix 75mgQD75mgQDAt t ti 20 QNAt t ti 20 QNAtorvastatin 20mg QNAtorvastatin 20mg QNAspirin 100mg QNAspirin 100mg QNB il 5 QDB il 5 QDBenazepril 5mgQDBenazepril 5mgQDBetaloc 12.5mgBIDBetaloc 12.5mgBIDI bid it t 10 TIDI bid it t 10 TIDIsosorbide mononitrate 10mg TIDIsosorbide mononitrate 10mg TIDLow molecular weight heparin calcium 0.4mlLow molecular weight heparin calcium 0.4ml：：Subcutaneous injection 1/12hSubcutaneous injection 1/12hSubcutaneous injection 1/12hSubcutaneous injection 1/12hLoad Dose:Plavix 300mg; Aspirin 300mgLoad Dose:Plavix 300mg; Aspirin 300mg..

Diagnostic coronary angiographyDiagnostic coronary angiography20102010 1111 01 17 2201 17 2220102010--1111--01,17:2201,17:22

mRCA 30mRCA 30--50%,50%,ddRCA 70RCA 70--80% stenosis80% stenosispLAD 100% occlusion.pLAD 100% occlusion.LCX 50LCX 50--60% diffuse stenosis60% diffuse stenosisLCX 50LCX 50 60% diffuse stenosis60% diffuse stenosis

Diagnostic coronary angiographyDiagnostic coronary angiographyDiagnostic coronary angiographyDiagnostic coronary angiography




questionsquestionsquestionsquestions

According to the result of CAG, anterior wall According to the result of CAG, anterior wall myocardial infarction was diagnosed,but the myocardial infarction was diagnosed,but the biomarkers were normal, ultrosonography was biomarkers were normal, ultrosonography was normal, and the collateral artery to distal LAD normal, and the collateral artery to distal LAD was not found, the patient’s chief complaint is just was not found, the patient’s chief complaint is just onset of chest pain 3 daysonset of chest pain 3 days . . so what is the onset so what is the onset time of AMI?time of AMI? Just for 3 days? But Q wave were Just for 3 days? But Q wave were not found in chest leads,and ST segment elevation not found in chest leads,and ST segment elevation were not recorded in chest leads.were not recorded in chest leads.

questionsquestionsquestionsquestions

Is the total occluded lesion a CTO ? Is the total occluded lesion a CTO ? Maybe,but no collateral circulation, no Maybe,but no collateral circulation, no y , ,y , ,dLAD appears.dLAD appears.As the symptom just for 3 days we thinkAs the symptom just for 3 days we thinkAs the symptom just for 3 days,we think As the symptom just for 3 days,we think this lesion happened to totally occluded as this lesion happened to totally occluded as angiography time.but ECG has not shown angiography time.but ECG has not shown ST segment elevation during procedure. Is ST segment elevation during procedure. Is g g pg g pit right or wrong?it right or wrong?

What is the strategy?What is the strategy?What is the strategy?What is the strategy?

CABG vs PCI?CABG vs PCI?As we thinked the occluded lesion is acute,As we thinked the occluded lesion is acute,As we thinked the occluded lesion is acute, As we thinked the occluded lesion is acute, PCI was adviced to the family, and PCI was adviced to the family, and recommended to do it guided by IVUSrecommended to do it guided by IVUSrecommended to do it guided by IVUS. recommended to do it guided by IVUS. Because the cost of IVUS 13,000 RMB is not Because the cost of IVUS 13,000 RMB is not afforded by insurance bureau, the family afforded by insurance bureau, the family accepted PCI and refused IVUS.accepted PCI and refused IVUS.pp

P d f fi t PCIP d f fi t PCIProcedure of first PCI Procedure of first PCI 20112011--1111--1,17:491,17:49

ApproachApproach：：TransTrans--right Radial Arteryright Radial ArteryGC:6F EBU3.5GC:6F EBU3.5GW:0 014”PILOT50GW:0 014”PILOT50GW:0.014”PILOT50GW:0.014”PILOT50prepre--dilated balloondilated balloon：：RYUJIN2.5x15mmRYUJIN2.5x15mm；；

postpost--dilated balloondilated balloon：：KONGOU3.0x15mmKONGOU3.0x15mmSt t EXCEL2 75 24St t EXCEL2 75 24Stent: EXCEL2.75x24mm;Stent: EXCEL2.75x24mm;

Procedure of first PCIProcedure of first PCIProcedure of first PCIProcedure of first PCI








Procedure of first PCI Procedure of first PCI finished at 18:01 2011finished at 18:01 2011 1111 11finished at 18:01, 2011finished at 18:01, 2011--1111--11

After we deployed one stent in LAD, the flow of LAD got well.

Hidden ghost?Hidden ghost?Hidden ghost?Hidden ghost?

Do you notice the segment at the distal edge of Do you notice the segment at the distal edge of stent still has stenosis? Or vulnerable stent still has stenosis? Or vulnerable plaque? Or dissections occurred?plaque? Or dissections occurred?

But the flow is TIMI 3 gradeBut the flow is TIMI 3 gradeBut the flow is TIMI 3 grade.But the flow is TIMI 3 grade.Acceptable result?Acceptable result?Simple is best?Simple is best?IVUS t d t tf l thiIVUS t d t tf l thi !!!!!!IVUS not done, a great regretful thingIVUS not done, a great regretful thing!!!!!!

Disaster eventDisaster eventDisaster eventDisaster event

iiAfter PCI,the patient was safely transferred After PCI,the patient was safely transferred to CCU, Heparin and Tirofiban Intravenous to CCU, Heparin and Tirofiban Intravenous infusion Instantly, but he complained chest infusion Instantly, but he complained chest pain with extra sweaty at 20:50 at the same pain with extra sweaty at 20:50 at the same day, The bedside ECG showed :Iday, The bedside ECG showed :I、、avLavL、、V1V1--V4 ST segment elevated 0.2V4 ST segment elevated 0.2--0.4mV,we 0.4mV,we considered considered acute thrombosis formationacute thrombosis formation in in the stent, so the patient was transferred to the stent, so the patient was transferred to ppcatheter lab catheter lab immediatelyimmediately , and performed , and performed the second coronary angiography.the second coronary angiography.y g g p yy g g p y

The second angiographyThe second angiographyg g p yg g p y20112011--1111--1,21:261,21:26

DiscussionDiscussionDiscussionDiscussion

What is the reason of acute inWhat is the reason of acute in--stent stent thrombosis?thrombosis?

DiscussionDiscussionDiscussionDiscussion

Stent thrombosis ma be related to clinical sit ationsStent thrombosis ma be related to clinical sit ationsStent thrombosis may be related to clinical situations, Stent thrombosis may be related to clinical situations, coronary artery disease and interventional operating coronary artery disease and interventional operating factors. factors. Diffuse small vessel disease, bifurcation lesions, Diffuse small vessel disease, bifurcation lesions, severe necrosis or lipidsevere necrosis or lipid--rich plaque target lesion, are rich plaque target lesion, are ll ill i h b i i k fh b i i k fall inall in--stent thrombosis risk factors.stent thrombosis risk factors.

Stent not full expansion, stent poor adherence, stent Stent not full expansion, stent poor adherence, stent malposition or residual stenosis where blood flowmalposition or residual stenosis where blood flowmalposition, or residual stenosis, where blood flow malposition, or residual stenosis, where blood flow cause shear stress to the stent and vessel wall, maybe cause shear stress to the stent and vessel wall, maybe the cause of stent thrombosis. the cause of stent thrombosis. Stents do not full cover the culprit lesions length, Stents do not full cover the culprit lesions length, more than one culprit lesions, or the stent dilatation more than one culprit lesions, or the stent dilatation

d di l d di i h b i dd di l d di i h b i dcaused distal edge dissections, thrombosis occurred.caused distal edge dissections, thrombosis occurred.

What can help you do perfect PCI What can help you do perfect PCI operation?operation?

IVUS maybe.IVUS maybe.But the family turned down it, for economicBut the family turned down it, for economicBut the family turned down it, for economic But the family turned down it, for economic reasons.reasons.

Procedure of second PCIProcedure of second PCIProcedure of second PCIProcedure of second PCI

ApproachApproach：：TransTrans--right Radial Arteryright Radial ArteryGC:6F EBU3.5GC:6F EBU3.5GC:6F EBU3.5GC:6F EBU3.5GW:0.014”BMWGW:0.014”BMWprepre--dilated balloondilated balloon：：RYUJIN2.5x15mmRYUJIN2.5x15mm；；

postpost--dilated balloondilated balloon：：NC SPRINTERNC SPRINTERpostpost--dilated balloondilated balloon：：NC SPRINTER NC SPRINTER 3.0x15mm3.0x15mmStent: EXCEL2.75x24mmStent: EXCEL2.75x24mm





Just balloon dilation or another stent?Just balloon dilation or another stent?Just balloon dilation or another stent?Just balloon dilation or another stent?

As angiogram showed, pLAD still had stenosis As angiogram showed, pLAD still had stenosis lesions distal to the first stent, maybe lesions distal to the first stent, maybe , y, ydissections occurred after deployment of the dissections occurred after deployment of the first stentfirst stentfirst stent.first stent.or more than one the culprit lesions in or more than one the culprit lesions in pLAD.stent not full cover the lesions segment.pLAD.stent not full cover the lesions segment.

Just balloon dilation or another stent?Just balloon dilation or another stent?Just balloon dilation or another stent?Just balloon dilation or another stent?

We decieded to deploy another stent to full We decieded to deploy another stent to full cover the lesion segment.cover the lesion segment.gg



P d f d PCIP d f d PCIProcedure of second PCI Procedure of second PCI finished at 21:50finished at 21:50

Procedure of second PCI Procedure of second PCI finished at 21:50finished at 21:50

Post the second PCIPost the second PCIPost the second PCIPost the second PCI

Myocardial biomarkers: CK 1262U/L, CK Myocardial biomarkers: CK 1262U/L, CK 129U/L, LDH 308U/L, AST 124U/L.129U/L, LDH 308U/L, AST 124U/L., ,, ,Heparin and Tirofiban Intravenous infusion Heparin and Tirofiban Intravenous infusion Instantly 72 hoursInstantly 72 hoursInstantly 72 hours.Instantly 72 hours.

Discharged diagnosisDischarged diagnosisDischarged diagnosisDischarged diagnosis

CHDCHDAnterior wall AMIAnterior wall AMIAnterior wall AMIAnterior wall AMIAcute anterior wall myocardial reinfarctionAcute anterior wall myocardial reinfarctionAcute instent thrombosisAcute instent thrombosisLeft ventricular wall aneuorysmLeft ventricular wall aneuorysmLeft ventricular wall aneuorysmLeft ventricular wall aneuorysmKillip IIKillip IIPneumoniaPneumonia

Discharge medicationsDischarge medicationsDischarge medications Discharge medications

Asprin 300mg QNAsprin 300mg QNAsprin 300mg QNAsprin 300mg QNPlavix 75mg QDPlavix 75mg QDAtorvastatin 20mg QNAtorvastatin 20mg QNBetaloc 12 5 BIDBetaloc 12 5 BIDBetaloc 12.5 BIDBetaloc 12.5 BIDIsosorbide mononitrate 10mg TIDIsosorbide mononitrate 10mg TIDTrimetazidine.20mg TIDTrimetazidine.20mg TID

FollowFollow upupFollowFollow--upup

6 months Follow6 months Follow--up: no discomfort up: no discomfort complaintscomplaintspp

Lesson from this caseLesson from this caseLesson from this caseLesson from this case

IVUS is a good eye to find the culprit lesions in IVUS is a good eye to find the culprit lesions in artery lumen in primary PCI.artery lumen in primary PCI.y p yy p y

PCI guided by IVUS may avoid acute inPCI guided by IVUS may avoid acute in--stent stent thrombosis then avoid reinfarction or AMIthrombosis then avoid reinfarction or AMIthrombosis, then avoid reinfarction or AMI. thrombosis, then avoid reinfarction or AMI.

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AiAcute inn--stent tstent thbihrombosis postost--PCI iPCI