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A 63 year old man was transferred to our hospital in an emergency following the onset of chest pain two hours previously. The ECG showed normal sinus rhythm with ST segment elevation in the anterolateral leads. He had a history of active Crohn’s disease.
An urgent cardiac catheterisation revealed a 99% mid-left anterior descending artery (LAD) stenosis (culprit lesion) and a 99% stenosis of an aneurysmal right coronary artery (RCA) (panel A). It was decided to attempt percutaneous coronary intervention (PCI). A glycoprotein IIb/IIIa inhibitor was not administered because of the bleeding risk related to Crohn’s disease. The LAD lesion was predilated and a stent 2.75 mm × 33 mm (Cypher, Cordis) was implanted with a TIMI grade 3 flow. Subsequently it was decided to treat the RCA stenosis. In order to avoid distal embolisation from mural thrombus within the ectatic segment, we opted to use a distal protection device (Filter Wire EX, Boston Scientific). Until now distal protection systems have been mainly used in the setting of acute coronary syndromes, and to treat thrombotic or degenerated saphenous vein graft stenosis.
After positioning the distal protection device, the RCA lesion was predilated with a 4.0 × 20 mm Maverik balloon at 12 atm. A 5.0 × 18 mm Express stent was then deployed at 16 atm. A massive embolisation occurred during angioplasty and stent implantation, resulting in a partial occlusion of the filter system but without distal embolisation (panel B). When the filter was retrieved a TIMI grade 3 distal flow was achieved and the no-reflow phenomenon did not occur (panel C). Inspection of the filter revealed the presence of many particles (panel D) which, at histological examination, appeared to be composed of fibrin, cholesterol crystal, foam cells, and amorphous material. These findings suggest that a large piece of intimal debris peeled off and was dislodged from the main plaque during the interventional procedure. The patient’s subsequent clinical course was uncomplicated.
The use of distal protection devices in the treatment of an RCA lesion within a diffuse ectatic segment, even in the angiographic absence of apparent thrombus, is suggested.