A case of immediate hyper acute stent thrombosis of ST segment elevation myocardial infarction patient after direct stenting combined with manual thrombectomy

초록

Case summary: 60 year old male visited the emergency room presenting chest pain. While briefly waiting for medical attention, the patient collapsed and lost mental alertness. Cardiopulmonary resuscitation was performed. Electrocardiogram rhythm showed ventricular fibrillation and defibrialtion shock was applied. Successful return of spontaneous circulation was acheicved and follow up electrocardiogram showed wide QRS interval with ST segment elevation at V1-V4 precordial leads also with II III AVF reciprocal ST segment depression. Emergency coronary angiogram revealed total occlusion of proximal LAD and diffuse irregular stenotic lesion at proximal RCA. Culprit vessel (LAD) was treatment with mechanical thrombectomy followed by direct DES implantation with TIMI flow 3. However, residual radio opaque lesion was seen at proximal LAD but no further procedure was done initially. Sequential DES stenting was done at p-RCA and follow up coronary angiogram of LAD was performed to re-assess the residual lesion at proximal LAD. Follow up LAD angiogram showed total occlusion of previous stent lesion. Immediate thrombectomy was performed and sequential high pressure adjunctive balloon angioplasty was done. TIMI flow 3 was achieved once again and the patients was stabilized. IVUS was seen to evaluate the cause of hyperacute stent thrombosis. IVUS showed significant amount of residual thrombus within the DES lesion. Considering the deleterious effect of excessive balloon angioplasty in acute coronary syndrome patients, no further procedure was performed. 5 days later, follow up angiogram was performed to evaluate the culprit lesion with OCT. OCT showed remnant heavy thrombus within previous stent site. This time, additional adjuctuive non-compliance balloon angioplasty was performed and thrombus burden was much more improved than before.