Case 55: PCI Manual - LIMA thrombosis

A patient presented with acute myocardial infarction due to thrombosis of the distal LIMA anastomosis. He was also hypotensive with systolic blood pressure of 90 mmHg. The thrombosed graft was wired with a Fielder FC wire, however balloon angioplasty and aspiration thrombectomy failed to restore antegrade flow. Laser was performed, but led to distal LIMA perforation. A 2.75x30 mm DES was placed from the LIMA into the LAD restoring TIMI 3 antegrade flow, followed by placement of a Graftmaster stent across the perforation segment, achieving hemostasis. The patient's hemodynamics stabilized and he had an uneventful recovery.

[@dr.sefaokar]

Thank you your presentaion

[@farukakturk5388]

Sir, Thank you for sharing this educational case. I have some questions. First of all what is the optimal duration of DAPT for covered stents? Covered stents are bulky devices how could you deliver it there? Did you shorthen guide catheter or used longer balloon and stent for approaching the culprit?

[@manosbrilakis]

Great points. My preference is for >12 months DAPT after Graftmaster placement given increased risk for stent thrombosis. In this cases delivery was not too difficult, but if it is then other strategies (such as use of guide extensions) may be useful. The covered stent did reach the lesion without needing to shorten the guide (but IMA guides are 90 cm long which helped).

[@AhmedElborae]

Thanks Dr Manos for this educational case. I want to ask about the size of the guide catheter, if it is 6F in this situation it can accommodate the graft master less than 4.0 diameter, but not together with balloon that allows ( block and deliver technique) to minimize the extravasation. In this situation , Do you recommend" ping-pong " technique? Thanks again

[@manosbrilakis]

Good point. In this case extravasation was relatively slow, so we did not do ping pong technique (which would be needed for having the blocking balloon in place while delivering a covered stent as you astutely point out). If there was a lot of bleeding through the perforation site, then would do ping pong.

[@nctbkh3718]

Thank you for your presentation. What is your DAPT strategy in patients with graft stent? 12 months or more?

[@manosbrilakis]

My personal approach is at least 12 months, but ideally longer (if the patient does not have increased bleeding risk) as Graftmaster stents have higher risk for stent thrombosis.