Case 27: PCI Manual: STEMI and shock

A patient presented with STEMI and underwent emergency coronary angiography that demonstrated LAD occlusion and an ulcerated lesion in the mid circumflex. The LAD was re-opened with balloon angioplasty followed by evaluation for surgery, but he was turned down for CABG. PCI of the circumflex lesion was complicated by no-reflow likely due to distal embolization. The patient subsequently had PEA arrest, treated with Lucas and VA-ECMO. This case highlights challenges associated with treatment of STEMI patients, including identifying the culprit lesion(s), preventing no reflow, and preventing and treating hemodynamic decompensation.

[@matheuscsmed]

Thank you, Matheus Silva

[@malsabri2024]

Thanks for this case. The Q is why you started to do the Lcx inspite that you have a good distal flow and totally occluded proximal LAD ? Because any complication during Lcx manipulation will be catastrophic .

[@manosbrilakis]

Point is well taken. We actually started from the LAD doing balloon angioplasty without stent placement due to small size and poor antegrade flow.

[@evandrofilhobr]

Nice case as always Dr. Brilakis. Why not direct stenting mid circ? Did you consider RCA PCI? Think despite RCTs this pt would be benefit from this strategy. You had MCS already set.

[@manosbrilakis]

Good points. I very rarely do direct stenting, as predilation helps assess the length of the lesion and also confirm that the lesion is expanding well. I think that RCA PCI would not have been a good idea based on the CULPRIT-AMI trial.

[@arkadiusznowak268]

IABP baloon seems to be too low in aorta . Dystal marker of baloon sould be on the level of bifurcation of trachea.

[@jorgemariopm]

Nice case and great presentation. What do you think about intra-coronary IIb/IIIA inhibitor previously to pre-dilation to prevent distal embolization or no re-flow? It is useful or not?

[@manosbrilakis]

Good point. Could have given GP IIb/IIIa based on the INFUSE-AMI results, but would probably have given it intravenously instead of intracoronary since there was not much visible circumflex thrombus. GP IIb/IIIa inhibitors do increase, however, the risk for bleeding.

[@tuanhoanh1198]

I have also tried radial artery approach for several STEMI case with cardiac shock but all of them required a cross to femoral pathway. Do you think femoral approach should be the default pathway for AMI with shock?

[@manosbrilakis]

Femoral access will be needed for hemodynamic support, but coronary angiography could probably still be performed using radial access in most patients.

[@tuanhoanh1198]

You suggest that there are 2 culprit lesions in this case, but how about if you only pci for LAD, other lesions wouod be left for pci later? I suppose, in that case, the situation may be less pernicious and concordant with shock circumstance with 1 culprit in LAD

[@manosbrilakis]

Retrospectively that might have been a good idea!

[@NikhilJha89]

Why to stent in erosion?

[@harsharao3555]

Nice case, what made you guys to get emergent echo?.

[@manosbrilakis]

Echo was done as patient was being evaluated for CABG.