- Primary PCI for myocardial infarction is usually a relatively easy procedure
- The plaque is usually very soft making passage of wire easy
- Sometimes the pre-existing plaque may be already calcified
- This with the presence of plaque upstream may make wire crossing a bit challenging
- If the plaque is hardened, a good supporting guide is useful
- Amplatz shaped guides provide good support
- However, due to its shape, while on one hand provides good support, on the other makes it easier to create dissection at the ostium
- The following patient presented with acute inferior ST-Elevation Myocardial Infarction
- The attending doctor started with an Ikari Left 3.5 guide from the radial artery
Baseline angiogram
- This baseline angiogram shows a complete occlusion at mid RCA
- The operator started with a 6F IL 3.5 guide from the right radial
1 inf stemi
- After trying for some time with a soft wire, he was unable to cross the lesion
- He decided to change to stiffer wire
- However, he was still not able to cross the lesion.
- Thinking that he needed a more supportive guide, he decided to change to an AL 1
2 cant cross
- Unfortunately, he caused dissection of the RCA ostium
3 change guide
- Finding that he could not rewire the RCA with the AL1 guide, he changed to JR4 guide
- In his panic, he wired into the subintimal space rather than the true lumen
4 diff wire
- Thinking that he has wired the true lumen, he decided to stent the RCA ostium
- In his haste, he has not realised that the wire is actually sitting in the false lumen
5 is this correct
- After deployment of the stent, the RCA is now completely occluded
- He decided that since patient is not complaining of chest pain, he would abandon the procedure
6 subint stnt
Discussion
- Some acute coronary syndrome occur on the background of pre-existing subtotal occlusion
- Wiring these lesions in the presence of fresh thrombus may sometimes be challenging
- I find that the use of a tapered tip wire such as XT-R is very useful
- The chances of finding a track is higher than normal work horse ‘soft’ wire
- Sometimes the use of good supporting catheter is necessary
- In this case, extreme care should have been taken when using the Amplatz type guide
- The operator should also be careful when the wire is sitting
- Unfortunately the wire was in the sub-intimal space when the stent is deployed
- Long term wise, if the myocardium is not damaged, there may a chance of re-opening this lesion via the retrograde path