Case presentation

A healthy 58-year-old man with several risk factors for coronary disease, including hypertension and dysplipidemia, developed severe left-sided substernal chest pain while walking down his driveway to get the mail. The pain migrated to his left arm and was associated with diaphoresis and dyspnea. The discomfort continued all night and he presented to a community hospital the next morning with ongoing residual chest pain. His initial electrocardiogram showed T-wave inversion inferiorly and his initial troponin was already elevated at 2.7 ng/mL. He was admitted to the hospital with a diagnosis of non-ST segment elevation myocardial infarction and was treated with 300 mg clopidogrel, aspirin, unfractionated heparin, beta-blocker, and nitrates. He quickly became pain-free, and the cardiology consultant recommended urgent cardiac catheterization. The patient was at a facility that offered cardiac catheterization, had recently begun a percutaneous coronary interventional program, but did not have an open-heart surgery program; the nearest hospital offering open-heart surgery was 30 miles away.

Cardiac catheterization

The patient stayed at the community hospital and the procedure was scheduled with an experienced interventional cardiologist (who performed more than 200 interventions each year), whose primary practice was at a large university hospital with surgical backup. Left ventricular function appeared normal with no wall motion abnormalities. The right coronary artery had a severe stenosis in the proximal segment; this lesion appeared hazy, but there was normal TIMI flow in the artery (Figure 45-1 and Video 45-1). The left coronary angiogram was notable for a normal appearing circumflex artery and a moderate lesion in the midsegment of the left anterior descending (LAD) artery (Figures 45-2, 45-3). To further assess the hemodynamic significance of the LAD stenosis, the operator measured fractional flow reserve (FFR); this calculated to 0.84 and was therefore deemed not significant.

FIGURE 45-1 This is a left anterior oblique angiogram of the right coronary artery, showing the severe lesion with a hazy appearance in the proximal right coronary artery.

FIGURE 45-2 This is a representative image of the left coronary artery in the right anterior oblique caudal projection, showing no significant disease of the left circumflex artery.

FIGURE 45-3 There was a moderate stenosis noted in the mid-segment of the left anterior descending artery. This lesion was assessed by fractional flow reserve (FFR) using a pressure wire (arrow shows position of the pressure transducer); FFR was 0.84 and thus was not considered a significant lesion.

Based on the patient’s clinical syndrome and the angiogram, the disease in the right coronary artery appeared to represent the culprit lesion responsible for the acute coronary syndrome. The interventional cardiologist thought the lesion appeared fairly straightforward, without high-risk features that would necessarily preclude performance of a stenting procedure at a facility without surgical backup.

Thus, the interventionalist proceeded with PCI and placed a 6 French right Judkins guide catheter in the right coronary artery after procedural anticoagulation was achieved with bivalirudin. The operator first dilated the lesion with a 3.0 mm diameter by 20 mm long compliant balloon and then placed a 4.0 mm diameter by 28 mm long drug-eluting stent. As the operator was satisfied with the angiographic result in several views (Figures 45-4, 45-5 and Videos 45-2, 45-3), intravascular ultrasound was not performed and the case was terminated. The patient felt well with no chest pain or discomfort. Hemostasis was easily accomplished with a vascular closure device.

FIGURE 45-4 The left anterior oblique projection of the right coronary artery following stenting showed an excellent angiographic result.

FIGURE 45-5 The right anterior oblique projection of the right coronary artery following stenting showed an excellent angiographic result.

The patient had been moved off the cardiac catheterization laboratory table and onto a stretcher awaiting transfer to his hospital bed when he reported chest pain, diaphoresis, and nausea. The monitor leads showed marked ST-segment elevation and sinus bradycardia. Fearing acute stent thrombosis, the patient was immediately returned to the cardiac catheterization laboratory and the physician quickly regained arterial access and imaged the right coronary artery. The right coronary was completely occluded distal to the stent and there appeared to be a linear dissection beyond the distal end of the stent that was not apparent on the post-PCI films (Figure 45-6). At this point, the patient had ongoing severe chest pain and bradycardia but maintained an adequate arterial pressure.

FIGURE 45-6 This right coronary angiogram was obtained shortly after the patient noted the onset of severe chest pain associated with ST-segment elevation. The artery is now closed and there is a dissection flap at the distal end of the stent (arrow).

The operator administered atropine, unfractionated heparin, and eptifibatide, and attempted to open the artery. Gaining the true lumen proved extremely difficult, but finally the operator was able to insert floppy-tipped guidewires into both the posterior descending and the posterolateral branches (Figure 45-7