Be careful with that wire

  • 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

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Wire was pushed down

What the doctor has failed to notice was that the wire had gone into the plaque

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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

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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
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