Abstract Body (Do not enter title and authors here): Introduction
Subacute stent thrombosis (ST) is related to high rates of cardiac reinfarction. We present a case of reinfarction from ST. The patient’s chest pain (CP) was not alleviated with initial revascularization of his left circumflex (LCx) ST, requiring PCI to his right coronary artery (RCA) chronic total occlusion (CTO). This is a novel approach to CTO PCI which is traditionally a non-urgent procedure.
Case
A 53-year-old male with a history of coronary artery disease and surgical turndown presented to the ED with CP. Two weeks prior he had impella guided LM bifurcation PCI with DES and ramus intermedius (RI) angioplasty (PTA) but was nonadherent to clopidogrel. He had a BP of 127/85, HR of 65, and was on room air. Exam was unremarkable. His EKG was in sinus rhythm with S-T depressions ~1mm in leads V1-V4 concerning for posterior infarction. HS-troponin (HST) was 60. Angiography (CA) showed thrombotic occlusion of his LCx DES (Fig 1a) and an RCA CTO (Fig 1c). Optical coherence tomography (OCT) revealed DES struts overlying the ostial LCx concerning for mechanical deformation from carinal shift. OCT guided PTA and laser thrombectomy (LT) of the LCx led to TIMI-3 Flow. LT and kissing balloon inflation (BI) was performed on the LAD and LCx to reshape the carina. HST peaked at 116,012. He had CCS Class IV CP despite medical therapy and returned for re-look CA with TIMI-3 flow in the left-sided circulation without thrombus (Fig 1b). He had PCI to his distal RCA CTO with two DES and TIMI-3 flow in the RCA (Fig 1d). He did not have recurrence of CP.
Discussion
Bifurcation PCI leads to challenges from anatomic reconfiguration, metallic DES deformity, and changes in blood flow leading to increased risk of distal ST. This patient’s CA demonstrated LM DES material overlying the LCx from carinal shifting which likely led to interrupted flow dynamics. His LCx ST was partly due to this stasis and his clopidogrel nonadherence. Despite PCI of his LCx his CP remained with poor collateral flow from the left circulation. While CTO procedures are typically done non urgently, emergent intervention on our patient’s RCA CTO led to complete resolution of his CP and clear benefit for symptomatic management.