Case report
A 62-year-old man presented to his family doctor with a history of chest pain at rest for the past four days. He was diagnosed with non-ST-segment elevation myocardial infarction (NSTEMI) and was referred to our institute. His blood pressure and heart rate were 134/67 mmHg and 81 beats/min, respectively. The physical examination revealed a high body mass index (27.6 kg/m2) and normal heart sounds without peripheral edema.
The patient had a 20 years history of smoking along with dyslipidemia and hyperuricemia, managed with anti-dyslipidemic and anti-hyperuricemic medications. Laboratory investigations revealed 0.853 ng/ml of troponin T level and 892 pg/ml of NT-proBNP level. Electrocardiography showed a regular sinus rhythm with abnormal Q waves and negative T waves in the inferior leads, and ST-segment depression in leads V4–6. Also, mild hypokinesis was observed in the inferior area with a left ventricular ejection fraction of 59.6%. Coronary angiography (CAG) revealed total thrombotic occlusion of the ostial right coronary artery (RCA) and no organic stenosis in the left coronary artery (Figure 1). Urgent PCI was performed. The patient was administered with aspirin (200 mg), prasugrel (20 mg), and heparin (9,000 international units). An 8-French Judkins Right catheter (Hyperion JR 3.5, ASAHI INTECC Co., Ltd., Seto, Japan) was inserted from the femoral artery and engaged in the RCA, and a 0.014-inch guidewire (ULTIMATE bros 3, ASAHI INTECC Co., Ltd., Seto, Japan) was passed into the thrombotic lesion with a microcatheter. Although, balloon dilatation (2.5 mm) was performed in the ostium of the RCA (Figure 2A), reperfusion could not be achieved (Figure 2B). Subsequently, aspiration thrombectomy was attempted several times using an aspiration catheter (Rebirth Pro2; NIPRO Co, Osaka, Japan). However, the subsequent CAG showed that a high thrombus burden remained in the RCA (Supplemental file). After CAG, the patient suddenly developed a headache, dysarthria, and paralysis of the right upper and lower limbs. We suspected acute cerebral infarction, and the neuro-interventionalist immediately performed cerebral angiography, which showed complete occlusion of the right posterior cerebral artery (Figure 3A). Endovascular thrombectomy was performed by a direct aspiration first pass technique using the AXS Catalyst 6 catheter (Stryker Japan K.K., Tokyo, Japan). The tip of the AXS Catalyst 6 catheter reached the occluded site, and the thrombus was aspirated from the tip. The right posterior cerebral artery was successfully re-perfused (Figure 3B). No further PCI procedures were performed, and the final thrombolysis in myocardial infarction flow was of grade 2. An intra-aortic balloon pump (IABP) was added to improve coronary flow and was removed 3 days later. Follow-up coronary computed tomography angiography revealed a residual thrombus in the RCA after 1 week (Figure 4). However, the patient continued with rehabilitation and was discharged with slight right upper limb paralysis on day 19. He did not complain of chest discomfort or dyspnea upon discharge.