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49yo male, with underlying Diabetes Mellitus and advance chronic kidney disease.  Admitted to a local hospital with Acute Inferior STEMI complicated with complete heart block. Patient was transferred to our center after thrombolysis with IV Streptokinase. On arrival patient was ill, requiring inotropic support IVI Noradrenaline.

ECG - Complete heart block with ST elevation II, III, AvF
Hb 9.3 g/dLPlatelet 195WBC 12.6Creatinine 636 umol/lUrea 20.7 mmol/l

TPM insertion done. Proceeded with angiogram. Left system showed no obvious obstruction. The right system was engaged with Guide JR 3.5,6F, showed total occlusion of RCA, heavy thrombus in large a caliber RCA.Suction done with PENUMBRA, red thrombus aspirated. We did not proceed with stenting due to heavy thrombus load. Patient was given IV Aggrastat followed by daily S/C Clexane for anticoagulation.Patient was stable in CCU. TPM removed.Restudied 1 week later. 

Restudied 1 week later.RCA still shows heavy thrombus load. IVUS done. SPIDERFX 5.0mm inserted at distal RCA.Prepare lesion with RYUREI 2.5/15mm.Stented mid segment with MEGATRON 3.5/32mm.Had much difficulty trying to deliver the 2^ndstent MEGATRON 4.0/28mm.As we were attempting to deliver the stent, the SPIDERFX migrated up to the level mid RCA into the 1^st stent.We then used GUIDEPLUS guide extension to improve support. Successfully  delivered stent.IVUS done.Post dilated with NC EMERGE 5.0/8mm, however unable to deliver balloon beyond proximal edge of stentSPIDERFX removed. Upon removal, thrombus found on mesh.RUNTHROUGH FLOPPY sent down RCA. Second wire GRANDSLAM down RCA for better support. IVUS to confirm wire position.Continue to post dilate with NC 5.0/8mm at 8-12atmIVUS done.Then continue dilatation with 6.0/8mm at 8-12atmIVUS done           

Issues anticipated prior to procedure:-Large vessel size with high discrepancy between proximal and mid segment, estimated 5-6mm proximally.-Thrombus migration-Difficulty crossing lesion and delivering devices, as encountered during initial angiogram. -Extent of thrombus load maybe under estimated angiographically.Solution for each anticipated problem planned prior to procedure including the deployment of a versatile stent with high expansion capacity.Patient was reviewed 2 months later. Repeat angiography done with IVUS, stent patent with good apposition.