CORONARY - Acute Coronary Syndromes (STEMI, NSTE-ACS)
Culprit Confusion During Primary Percutaneous Coronary Intervention: Do You Touch the Chronic Total Occlusion?
Koon Wee Koay1, NEE HOOI TAN, Muhamad Ali SK Abdul Kader1
Penang General Hospital, Malaysia1,
Mdm SNS is a 33 years old lady who had a history of young stroke with right hemiparesis presented to a district hospital with acute onset of chest pain associated with dyspnea and sweating which lasted for 1 hour. Upon arrival at the district hospital, her blood pressure 120/80mmHg, pulse rate 96 beats per minute, oxygen saturation 98% under room air.Physical examination was normal.She was referred to Penang General Hospital for Primary Percutaneous Coronary Intervention after ECG was done.
ECG showed sinus rhythm and ST elevation at lead I, aVL and V2 with reciprocal changes at lead II, III and aVF.
We need to have high index of suspicion when coronary angiography showed 'unusual' artery course. Multiple angiographic view is vital whenever there is doubt. The first stent was actually at Diagonal branch instead of LAD. The true LAD is a chronic total occlusion confirmed by contralateral contrast injection.Treating a Chronic Total Occlusion in acute STEMI can be challenging and it can be done in certain case when patient is hemodynamically stable and the operator has experience in managing chronic occlusion. For this case, it will be more difficult to cross the Chronic Total Occlusion of mid-LAD in the future once the jailed proximal LAD- Diagonal stents endothelialized.