A Rare Case of STEMI
Dr. Zin Mar Mar THAN
Tan Tock Seng Hospital, Singapore
A 63-year-old man presented with sudden severe chest pain with ECG showing ST elevation in inferior leads. He has past history of hypertension, TIA, stage 4 chronic kidney disease. He also has history of chronic venous insufficiency with LSV ablation and right iliac vein stenosis with stenting. He is currently on Rivaroxaban.
Urgent diagnostic cardiac catheterization showed mid LCX aneurysm and mild stenosis in mid LAD (Figure 1, Figure 2). There was a huge aneurysm in proximal to mid RCA with TIMI 0 flow (Figure 3, Figure 4). Operator tried to continue PCI and attempted wiring across the aneurysmal segment to recanalize the RCA (Figure 5, Figure 6). After multiple attempts, operator failed to wire across the mid RCA and finally ended up with bad dissection (Figure 7).
Because of complication, further PCI was aborted and patient was transferred to CCU for further observation. The hemodynamic condition is stable. Echocardiography showed wall motion impairment in the inferior wall and small amount of pericardial effusion. Subsequent CTA showed thrombosed RCA aneurysm with no distal flow (Figure 8). Perfusion scan showed large full thickness of infarct with no viability.
Lesson to learn:
Coronary aneurysm thrombosis can present with acute coronary syndrome. In the situation in which the success rate of primary PCI is difficult, can consider IC thrombolytic before creating complication.