A 51-year-old lady, a known case of diabetes, hypertension, hypothyroidism & end stage renal disease on maintenance hemodialysis, presented with the complaints of shortness of breath and exertional chest discomfort for 8 hours. She was a renal transplant candidate. On physical examination, her heart rate was 96 beats per minute, blood pressure 170/80 mm of Hg. On auscultation, there was bilateral basal crepitations in her both lung fields. 

Her high sensitivity-troponin I was raised, serum creatinine was 7.21 mg/dl, serum urea 130 mg/dl, hemoglobin 9.7 gm/dl & calculated e-GFR was 6 ml/min/1.73 m².

She underwent coronary angiogram which showed triple vessel coronary artery disease with 90% lesion in left anterior descending artery, significant stenosis of proximal segment of diagonal branch & 70-80% lesion in left circumflex artery. Her right coronary artery was 100% occluded form its proximal segment with collaterals arising from the left coronary.

We took a heart team approach. After counselling with the patient and a discussion with a nephrologist, we decided to go for PCI. First, we took a cine of RCA by contralateral dual injection. J-CTO score was 2. Then RCA was wired by antegrade wire escalation. A run-through intermediate wire crossed the lesion with the help of a microcatheter. After adequate pre-dilatation, a 2.75X38 mm DES was deployed in distal RCA & another 3.5X32 mm DES was deployed in proximal to mid RCA. After adequate post dilatation, RCA showed TIMI-III flow. Subsequently, a 3X48 mm DES was deployed in proximal to mid LAD & another 2.5X28 mm DES was deployed in LCX. Her in-hospital stay was uneventful, and she was discharged on 4th day on dual antiplatelet (Aspirin and Clopidogrel). She was doing well on her follow-up after 2 weeks. But on 28th day of her PCI, she again got admitted through ER with fever, gum bleeding and multiple bruises all over the body for 4 days. She was diagnosed as a case of Dengue fever with severe thrombocytopenia. That was a double-edged sword situation. Her platelet count was 40,000/micro liter, which decreased up to 20,000/micro liter. Dual Antiplatelets were stopped immediately after hospitalization. Fresh frozen plasma and apheresis platelet were transfused. We monitored her platelet count regularly. After 7 days, when her count was increased to 1,00,000/micro liters, we first started clopidogrel and after 2 days, aspirin. She had been doing well since then.

An end stage renal disease patient with high bleeding risk along with dengue fever and recent angioplasty was a difficult scenario for an interventional cardiologist. Proper counselling, assurance, diagnosis and treatment of underlying cause along with proper drug treatment are required to tackle such double-edged sword situation.