Flush Occlusion

Case Summary

A 67-year-old male presented with sudden onset of dyspnoea in context of diabetes and asthma. He was a delayed presentation, ambulance field transmission anterior STEMI and was found to be in acute pulmonary oedema, complete heart block and shock, requiring intubation.ECG

Bilateral femoral arterial access. Bilateral femoral arteriogran to document disease and vessel calibre for cardiac support device insertion. Upfront IABP left CFA prior to PCI (notion of support before Reperfusion concept yet to be clinically proven). 7Fr EBU 3.5 guide revealed “flush” Ostial LAD occlusion with calcified ostial lesion and semi-organised thrombus. Initial Sion Black wire able to penetrate lateral branch of diagonal which was recognised. A second Sion Black wired in the LAO-caudal view also penetrated first diagonal but into the more medial division. This occluded bifurcating diagonal was ballooned with 1.5mm balloon allowing passage of a Crusade Micro-catheter over Rx segment. Sion Black wire through OTW lumen of Crusade Micro-catheter allowed wiring of LAD through side port. Flow established with 2.5mm balloon dilatation and  IVUS revealed mid LAD 2.0mm diameter and ostial LAD heavily calcified (>180 degrees) with a proximal reference 4.0mm diameter (vessel diameter -ie EEM to EEM). The calcification necessitated added lesion preparation which proceeded with LaCrosse NSE Alpha 2.75mm scoring balloon to ostial LAD resulted in “No-Reflow”. This often occurs in STEMI-Pci and is a result of a combination of factors including thrombus distal embolisation, tissue factor release, myocardial oedema, vasoconstriction…. Orsiro DES (2.5x22mm) implanted into ostial LAD, post dilated with 3.5mm NC proximally with persistent “No-Reflow”. High dose intra-coronary adenosine (25mg total in aliquots) delivered via Crusade micro-catheter placed in mid to distal LAD with improved flow. Lesion at distal stent-edge of ostial stent covered with 2.5x13mm Orsiro DES. IVUS confirmed excellent deployed and sized stented segment. Persistent shock despite IABP resulted in referral for VA-ECMO.

Challenges encountered

Complex wiring of flush ostial occlusion of calcified LAD with “No-Reflow”

Equipment

  • Crusade (dual lumen) micro-catheter
  • LaCrosse NSE Alpha Scoring Balloon
  • OptiCross 3F IVUS
  • 7.5F 50cc IABP
  • Asahi Sion Black

Cineangiography

Learning points:

  • IABP can be introduced through a larger sheath as proprietary sheath specifications maybe too tight (ie for 7.5 F IABP a regular 8F or 9F sheath makes it easy) if the Balloon Pump Sheath is inadequate/resistant to insertion
  • Crusade dual lumen micro-catheter has many uses including provision of support for difficult wiring of side branches with unfavorable angles or calcific plaque
  • Crusade micro-catheter can be used to deliver intra-coronary medications whilst maintaining wire position
  • No-Reflow can be treated with high dose intra-coronary adenosine. Other options include Verapamil, Nicardipine or nitroprusside
  • Coronary flow in non-culprit arteries are reduced in the setting of STEMI
  • Coronary vasospasm common in all coronary vessels in STEMI and makes stent sizing difficult (often extremely undersized) if imaging is. not performed
  • Severe “no reflow” which occurs after initial balloon inflation can result in mortality and often reflect extensive infarction with late presentation – no effective treatment  known
  • Ostial LAD occlusion involves distal L main and stenting most likely has some encroachment over LCx origin
  • Intracoronay imaging is recommended but not mandatory
  • if L main is stented , stent-undersizing is common if intracoronary imaging is not used
  • Ideally VA-ECMO should be inserted prior to PCI (this is currently not possible in our service)
  • Patients presenting in cardiogenic shock as a result of STEMI has a high mortality 40–50%
  • Anterior STEMI with complete heart block on ECG suggest a very proximal LAD occlusion and denotes a worse prognosis

 

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