• Images in cardiology

A 58 year old male smoker who has hypertension and diabetes mellitus presented with acute anterior ST segment elevation myocardial infarction (MI). He was initially treated with thrombolytic therapy—30 mg of intravenous bolus dose of TNK-TPA (Tenecteplase, Metalyse) and heparin. A 90 minute angiogram showed a mid left anterior descending (LAD) 80% ulcerative hazy critical lesion with TIMI grade 2 flow down LAD territory (panel A). In view of ongoing chest pain, incomplete ST segment resolution, and the angiographic findings seen in this patient, rescue angioplasty (PTCA) was performed. The LAD was wired directly with a 4.0 Angioguard filter (Cordis, Johnson & Johnson Interventional Systems, New Jersey, USA) and secured in the mid to distal LAD segment. The flow down LAD territory remained the same, with TIMI 2 flow, after deployment of the filter. The mid LAD lesion was then stented directly with a 3.0 mm × 13 mm Hepacoat stent (Cordis, Johnson & Johnson Intervention Systems). The stent was further post-dilated with a 3.5 mm × 9 mm Q monorail balloon (Boston Scientific Corporation, Massachusetts, USA). This resulted in TIMI 1 flow down the LAD territory with contrast staying at the level of the opened filter (panel B), most likely due to collection of thrombotic debris embolised distally from the lesion and trapped by the filter wire. At the same time, the patient experienced more chest pain. Once the Angioguard filter was closed and retrieved, TIMI 3 flow down the LAD was restored and the patient’s chest pain resolved (panel C). This case demonstrated the use of a distal protection device to prevent potentially disastrous complications in acute MI PTCA. Further clinical trials will be required to study the routine application of these types of devices in angioplasty for acute MI.

Mid LAD critical ulcerative hazy lesion (arrow) with TIMI 2 flow down LAD territory in the right anterior oblique deep cranial projection.

Post high-pressure dilatation of LAD stent (white arrow) showing TIMI 1 flow down LAD territory and stasis of contrast at the level of the opened Angioguard filter (black arrow) in the same projection.

Patent LAD stent with restoration of TIMI 3 flow down LAD territory in the same projection.