Thai male 65 years, Risk HT. 1 hr PTA had acute chest pain then developed VF arrest. Vital sign (after CPR ROSC) BP  117/69 mmHg HR 42 bpm. Heart: irregular, Lungs: fine crepitation both lungs  EKG showed ST elevation at II, III, aVF, ST depression at V1-V6 and High AV block. Echocardiogram showed LVEF 42%, HK at anterior, anterolateral and inferior wall, no significant Valvular heart disease. Chest x-ray showed bilateral pulmonary congestion.  

EKG showed ST elevation at II, III, aVF, ST depression at V1-V6 and High AV block. Echocardiogram showed LVEF 42%, HK at anterior, anterolateral and inferior wall, no significant Valvular heart disease. Chest x-ray showed bilateral pulmonary congestion. 

STEMI fast tract was activated. CAG via 7Fr RFA Sheath with Diagnostic catheter JL 4.0/6 Fr, JR 4.0/6Fr showed LM: Long LM, non significant stenosis, LAD: 70-80% stenosis proximal to mid LAD, 80-90% stenosis DG1, LCx: non significant stenosis, RCA: 100% stenosis mid RCA.PCI to RCA with Guiding catheter: JR 4.0/6Fr. Rinato wire to RCA, inserted Thrombuster II, Sapphire II pro inflated mRCA upto 10 atm. Biomatrix alpha 3.0 x 33 mm deployed mRCA 10 atm. Inserted IABP, Rt IJ pacemaker. 

After sent the patient back to CCU developed cardiac arrest with VF storm.Multiple defibrillator shocks was done. The patient was given IV Amiodarone then IV Lidocaine. Anti-tachycardia overdrive pacing can not break VF storm. VA ECMO was initiated. Stellate ganglion block was done and effectively stabilizing VF storm and sent the patient to perform PCI to LAD-DG. PCI to LAD-DG via Rt radial access using 6Fr sheath. Pass tortuous subclavian artery with Terumo wire. Guiding catheter: EBU 6/3.0 to LCA. Rinato pass to LAD, Sion pass to DG. 1.5 x 20 mm SC balloon inflated DG upto 6 atm. 2.5 x 15 mm sc balloon inflated p-mLAD upto 10 atm. Bimatrix alpha 2.75 x 33 mm deployed p-mLAD upto 8 atm. 

Learning points1.Stellate Ganglion Blockade can effectively stabilizing VF storm in patients for whom other therapies have failed.           2.VA ECMO was effective in maintaining hemodynamic status in VF storm patient.3.Hydrophilic wire facilitates the entry of wire through complex spiral tortuosities of subclavian artery.4.Tortuosities are not necessarily reflected in the contralateral arm, and success may be require a shift in access location.5.Pulling slightly catheter back along with guidewire straightens the tortuosity, allowing for smooth entry of a catheter in the ascending aorta.