Acute Vessel Closure in Rescue Percutaneous Coronary Intervention

Key words: coronary angiography, coronary spasm, percutaneous coronary intervention

A 45-year-old man presented with complaints of chest pain for 6 hours. Electrocardiogram was suggestive of inferior wall ST-segment elevation myocardial infarction (STEMI). The patient did not approve primary percutaneous coronary intervention (PCI) and was thrombolyzed with tenecteplase. However, there was no relief in chest pain and the patient developed cardiogenic shock. He was taken for rescue PCI. Left coronary angiogram showed complete thrombotic occlusion of the terminal obtuse marginal branch (Figure 1A; Video 1). The left circumflex artery was crossed with Runthrough extra floppy NS guidewire (Terumo). The patient developed worsening ST elevation and ventricular tachycardia, which was cardioverted by giving 2 shocks of 200 J. Left coronary angiogram showed occlusion of the left circumflex artery (LCX), right from the ostia (Figure 1B; Video 2). We initially thought of thrombus migration as the cause of acute vessel closure. Initially, dottering and subsequent dilation of the left circumflex was done with a 2.0 x 10 mm semicompliant balloon. The activated clotting time was 356 seconds. There was not much improvement in the blood flow in the LCX. We suspected coronary spasm and gave multiple 50 µg boluses of intracoronary nitroglycerin. Subsequently, brisk flow was established in the LCX (Figure 2; Video 3). The lesion was stented with a 2.75 x 18 mm everolimus-eluting stent. ST-segment changes settled after the PCI.

Guidewire-induced coronary spasm might be life threatening, as demonstrated in the present case. Balloon dilation might worsen the situation by enhancing the spasm. Prompt recognition and generous administration of coronary vasodilators are the mainstay of management.