- Presently, the standard treatment for heart attack is with stenting
- Most hospitals in Singapore have protocols in placed to establish blood flow in the infarct artery within 90 minutes of patient’s arrival in Accident and Emergency department
- This was a case of a 70 year old gentleman who presented with heart attack
- The case was performed by a newly qualified doctor
This was the initial angiogram showing the Left Anterior Descending artery is totally occluded
Wire was pushed down
What the doctor has failed to notice was that the wire had gone into the plaque
Not realising this, a thrombus aspiration catheter was forced down the artery
- This angiogram shows a Thrombuster (thrombectomy device) been pushed down
- No thrombus was aspirated
The dissection plane has been extended with resultant obstructed flow
- Earlier angiogram showed blood flowing to the distal LAD
He proceeded to dilated the lesion making the dissection worse
The flow is completely lost
- While taking the balloon out
- He inadvertently pulled out the wire
- The wire has been pulled up
- There is now no flow beyond the diagonal branch
- Despite trying with different wires and asking other doctors for assistance, the wire could not be recrossed into the LAD
- Since the patient no longer had any chest pain, the procedure was abandoned
Lesson
- Primary PCI is, more often than not, easy to treat because the thrombus is soft
- The wire can often cross easily
- However, one must not take this for granted
- The placement of wire must be meticulous
- In the angiogram that shows wire traversing the plaque, the operator should re-cross the vessel with the wire taking the path on the left
- I would use a 2nd wire to do this as pulling the 1st wire out may cause lost of flow
- Other device should not have been forced down
- This caused extension of dissection with haematoma in the sub-intimal space
- This will compress the true lumen
- Making entrance to the true lumen impossible as this operator found out