Case presentation

The onset of severe substernal chest pain awakened a 50-year-old diabetic woman without prior cardiac history from her sleep. The pain waxed and waned all morning until she finally presented to the emergency room 9 hours later. She was found to have an inferior wall ST-segment elevation myocardial infarction and was taken emergently to the cardiac catheterization laboratory. As suspected, based on the electrocardiographic changes, the right coronary artery was completely occluded (Figure 13-1); however, the operator was surprised to find severe and complex disease affecting the left anterior descending (LAD) and diagonal arteries (Figure 13-2 and Video 13-1) and moderate disease in the left circumflex artery (Figure 13-3 and Video 13-2). Lush collaterals filled the distal right coronary artery from the left coronary injections.

FIGURE 13-1 This is the occluded right coronary and the infarct-related artery.

FIGURE 13-2 The left anterior descending artery was severely diseased, with complex disease involving the diagonal and the bifurcation. There is also distal disease present (arrow).

FIGURE 13-3 There is moderate disease of the obtuse marginal artery and collaterals to the right coronary artery (arrow).

With the goal of achieving rapid reperfusion of the infarct-related artery, the operator decided to open the right coronary artery. This was promptly and successfully accomplished with balloon angioplasty followed by deployment of two 4.5 mm diameter bare-metal stents. The operator obtained an excellent luminal result and TIMI-3 flow (Figure 13-4 and Video 13-3).

FIGURE 13-4 Angiogram obtained after stenting the right coronary artery.

She recovered uneventfully from the acute infarction. During this hospitalization, a transthoracic echocardiogram showed an ejection fraction of 35% to 40% from an extensive inferoposterior wall motion abnormality. Uncertain about the optimal management of the incidentally-noted disease in the LAD and diagonal branch, her physician carefully considered several options. Surgical revascularization was thought to be unattractive because of the small caliber of the vessel and the presence of diffuse disease distally at the site of the usual graft anastomosis. Percutaneous revascularization would be complex and technically difficult because of the presence of bifurcation disease in the LAD and the small caliber of the LAD and diagonal vessels. In addition, given the recent sizeable inferior infarction and reduced left ventricular function, a PCI-related complication involving the LAD, such as abrupt vessel closure or loss of the diagonal side branch, might lead to serious morbidity and even death. Based on these considerations, her physician decided to pursue aggressive medical therapy as the initial management strategy. Thus, she was discharged on aspirin, clopidogrel, metoprolol, lisinopril, and atorvastatin.

At follow-up 2 months later, she reported significant shortness of breath associated with substernal chest pain when walking up the stairs at her home. A repeat echocardiogram showed improvement in left ventricular function with ejection fraction of 45% to 50%. Her physician again weighed the risks and benefits of surgery, percutaneous revascularization of the LAD, or continued medical therapy and referred her for stenting of the LAD.

Cardiac catheterization

She returned to the cardiac catheterization laboratory for an elective complex intervention of the LAD and diagonal. After achieving therapeutic anticoagulation, the operator advanced 0.014 inch floppy-tipped guidewires in both the LAD and diagonal and performed balloon angioplasty in the LAD with a 2.0 mm diameter by 20 mm long compliant balloon (Figure 13-5