A 34-year-old male was evacuated from a mining site to ED with retrosternal chest pain lasting 3 hours. An ECG confirmed inferior-posterior STEMI. Known risk factors included heavy smoking and alcohol use. Upon transfer from the ambulance, he suffered cardiac arrest. High-quality CPR achieved ROSC. Intubated with a GCS of 3, he presented in cardiogenic shock (BP 80/40).

Due to fluctuating high random blood glucose levels (374-456 mg/dL), primary percutaneous coronary intervention (PPCI) could not be performed within the optimal 120-minute window. Consequently, alteplase was used as a bailout strategy. The patient experienced several additional cardiac arrests and ROSC.Approximately 6 hours later, after achieving target random blood glucose levels, he was urgently transferred to the cath lab for rescue PCI

Rescue PCI was successful, with one drug-eluting stent (DES) placed in the posterior left circumflex (pLCX) and another in the posterior right coronary artery (pRCA), both of which were occluded with grade V thrombus

LCX:- Femoral Access- GC JL 3.5/6F- Thrombus grade V proximal LCX- Using Intuition wire can penetrate until distal LCX- Predilate with SC baloon Ikazuchi 2.0x20mm showed TIMI 2-3 Flow- Stent with DES Xience Xierra 2.75 x 23mm showed TIMI 3 Flow with no residual thrombus or stenosisRCA:- Femoral Access- Thrombus grade V proximal RCA- GC JR 3.5/6F- Using intuition wire can penetrate until distal RCA- Direct stent with DES Biomatrix Ultra 3.5x36mm showed TIMI 3 Flow with no residual thrombus or stenosis

1. Quick recognition and treatment of STEMI are vital, even in complex cases with rapid deterioration .2. Flexibility in treatment plans, such as using thrombolysis when PPCI isn’t timely, can be crucial.3. Managing complications like cardiogenic shock, renal and liver failure, and gastrointestinal bleeding is essential for patient recovery.4. Despite severe initial complications, intensive care can lead to successful recovery and return to normal life.