Case 154: Trifecta

A patient presented with NSTEMI and was found to have a severe mid LAD culprit lesion. After balloon angioplasty, dissection was seen in the proximal LAD, likely due to guide-induced dissection (Challenge 1). After wiring the circumflex and a diagonal branch originating within the area of dissection the proximal LAD was successfully stented pinching the ostium of the diagonal (Challenge 2). After rewiring the diagonal and kissing balloon angioplasty the diagonal lesion resolved, but a filling defect appeared on the proximal cicrcumflex (? plaque protrusion vs thrombus - Challenge 3a). After IVUS a stent was placed from the left main into the circumflex with a nice result, but a new filling defect appeared within the LAD (acute stent thrombosis, Challenge 3b). Cangrelor was administered, followed by Penumbra thrombectomy and balloon angioplasty of the LAD with a nice final result.

[@ImranAli-rg3ht]

Very nice case. Timely diagnosis of the complication is the key to save life.

[@Stentordoc]

Since the defect at the ostial LCx was probably thrombus, I would have first tried just a kissing balloon to try to avoid more metal there. But nice result!

[@manosbrilakis]

Great point, thank you

[@shangz0216]

Thanks for the educative case presentation.

[@TahirBezgin-wi1mw]

Would you have different result if GIIb/IIIa inhibitors was injected via intracoronary route during intervention?

[@karthikeyanselvaraj1801]

Sir ..just in retrospect...are..all these filling defects recurrent thrombus formation due to late dapt loading or inherent hypercoagulablity..shot during stent positioning in prox LAD @2.07 shows no haziness... probably thrombus dislodged...guess..also as guide catheter movement into LAD following balloon dilatation nd pull back rather than during stenting nd pull back of stent balloon is highly unlikely to occur ...may be as u wud normally do OCT nd thrombosuction wud ve avoided additional stents..just an alternative thought sir..may not be rite too🙏

[@manosbrilakis]

Great point, agree with you.

[@jadenlee3379]

Would you have different result if GIIb/IIIa inhibitors was injected via intravenous route before intervention?

[@manosbrilakis]

Yes, this would likely have prevented acute stent thrombosis