Acute Inferior ST-Elevation Myocardial Infarction Caused by Occlusion of a Giant Coronary Artery Aneurysm

J INVASIVE CARDIOL 2021;33(5):E401-E402. doi:10.25270/jic/20.00227

Key words: giant aneurysm, antiplatelet therapy, PCI, STEMI

A 79-year-old female with no significant prior medical history was transferred to our center for urgent angiography after presenting with presyncope and chest pain. Blood pressure was 57/37 mm Hg and heart rate was 44 bpm. Electrocardiogram (ECG) showed complete heart block with 5 mm of inferior ST elevation.

The femoral approach was used as the radial pulses were not palpable. A temporary pacing wire was inserted. Angiography revealed a giant aneurysm of the proximal right coronary artery (RCA) with thrombotic occlusion (Figure 1; Video 1). The occlusion was crossed using a Fielder XTR wire and Corsair Pro XS microcatheter (Asahi Intecc) (Figure 2; Video 2). A 6 Fr GuideLiner (Teleflex) was used to improve guide support. The distal vessel was blindly wired, with the vessel taking a tortuous course. Dilation with a 1.2 mm balloon restored Thrombolysis in Myocardial Infarction (TIMI) 2 flow. A huge burden of thrombus was seen throughout the vessel (Figures 3 and 4). A total of 8000 IU of intra-arteral heparin, a bolus of abciximab (0.25 mg/kg), and aspirin and ticagrelor were administered.

Attempts to pass a 6 Fr Thrombuster (Kaneka Medix Corporation) were unsuccessful due to the presence of a large spicule of calcium at the aneurysm outlet. A 1.5 mm Ikazuchi Zero balloon (Kaneka Medix Corp) restored TIMI 3 flow (Figure 5; Video 3). It was not possible to pass larger-diameter balloons. The patient was transferred to the intensive care unit on a 12-hour abciximab infusion.

Echocardiogram showed moderately reduced systolic function with inferior akinesis. The patient was discharged by day 5 on dabigitran and clopidogrel and remains well at 3-month follow-up.

View Accompanying Video Series Here

From the Cardiology Department, Wellington Hospital, Riddiford St, Wellington, New Zealand.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript accepted April 29, 2020.

The authors report that patient consent was provided for publication of the images used herein.

Address for correspondence: Sarah L Fairley, MBBCh, BAO, PhD, MRCP (UK), Cardiology Depart- ment, Wellington Hospital, Riddiford St, Wellington, NZ. Email: Sarah.Fairley@ccdhb.org.nz